PROMIS Physical Function and Pain Interference

Your answers stay on this device until you press Submit. If you press Submit, the completed form is sent over a secure connection and faxed to our office. You can also print the page or save it as a PDF instead.

Patient details

Patient name

Date of birth

Today's date

Needed if you submit the form to our office.

This form has two parts. Please answer every question by choosing one answer per question. A T-score is shown for each part once all of its questions are answered.

Physical Function

–T-score

· Raw score

For Physical Function, higher is better: a higher T-score means you can do more physical activities.

Pain Interference

–T-score

· Raw score

For Pain Interference, lower is better: a higher T-score means pain gets in the way of your life more.

Part 1: Physical Function

Please respond to each question or statement by marking one box per row.

Part 2: Pain Interference

In the past 7 days…

What T-scores mean

PROMIS scores are T-scores. A score of 50 is the average for the US general population. The standard deviation (SD) is 10, so a score of 40 or 60 is one SD away from average, and 30 or 70 is two SD away.

Physical Function: higher is better. A score below 50 means more limits in physical activity than the average adult.
Pain Interference: lower is better. A score above 50 means pain gets in the way of daily life more than for the average adult.

How it is scored: each answer is worth 1 to 5 points. The points are added up to a raw score, and the raw score is converted to a T-score with the official PROMIS scoring tables (HealthMeasures). A T-score is only shown when every question in that part is answered.

Send your form to our office

When your form is complete, press Submit. It is faxed securely to our office.

All forms

Other forms: PROMIS Global-10 · Oswestry Disability Index (ODI) · Roland-Morris Disability Questionnaire · WOMAC Osteoarthritis Index (hip or knee)

PROMIS Short Form v2.0 – Physical Function 10a and PROMIS Short Form v1.1 – Pain Interference 6a. © 2008–2016 PROMIS Health Organization and PROMIS Cooperative Group, and other individuals/entities that have contributed information and materials, used with the permission of the copyright holders. PROMIS® is a registered trademark of the U.S. Department of Health and Human Services. PROMIS instruments are available without license or fee for individual clinical use; see HealthMeasures.net for terms of use. Scoring tables: HealthMeasures PROMIS Physical Function User Manual and Scoring Instructions (Nov 24, 2025) and PROMIS Pain Interference Scoring Manual (Dec 5, 2023). This form is for patients of Garden State Medical Center. It is not a diagnosis or medical advice.