TARGET PROMIS-D – Parent - Formstack

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PROMIS-D – Parent

Copyright 7/29/2016 PROMIS Health Organization and PROMIS Cooperative Group

Summed Score

Child's Name*

First Name

Initial (optional)

Last Name

Child's Date of Birth*

Parent/Caregiver's Name*

First Name

Initial (optional)

Last Name

Parent/Caregiver's Email Address

Directions: Please respond to each statement by selecting one answer per row.

In the past 7 days...

1. My child could not stop feeling sad.*

Never (1) Almost Never (2) Sometimes (3) Often (4) Almost Always (5)

2. My child felt everything in his/her life went wrong.*

Never (1) Almost Never (2) Sometimes (3) Often (4) Almost Always (5)

3. My child felt like he/she couldn’t do anything right.*

Never (1) Almost Never (2) Sometimes (3) Often (4) Almost Always (5)

4. My child felt lonely.*

Never (1) Almost Never (2) Sometimes (3) Often (4) Almost Always (5)

5. My child felt sad.*

Never (1) Almost Never (2) Sometimes (3) Often (4) Almost Always (5)

6. It was hard for my child to have fun.*

Never (1) Almost Never (2) Sometimes (3) Often (4) Almost Always (5)