Last updated on March 2, 2022
Questionnaires are survey forms that include Patient Reported Outcome (PRO) measures which allow you to evaluate a patient's classification and track their progress over the course of their case.
There are ten CMS-approved ROMS measures used in Keet. This set of measures is comprised of five widely-used patient-reported outcomes surveys paired with a numerical pain rating scale (NPRS) for each measure.
6 MIPS PRO Questionnaires
- Disabilities of the Arm Shoulder and Hand (Quick DASH) Outcomes
- Available in English and Spanish
- Knee Outcomes Survey (KOS)
- Available in English and Spanish
- Lower Extremity Functional Scale (LEFS)
- Available in English and Spanish
- Modified Oswestry Low Back Pain Disability (MDQ)
- Available in English and Spanish
- Neck Pain & Disability Index (NDI)
- Available in English and Spanish
- Dizziness Handicap Inventory - MIPS
- Available in English
NON-MIPS Questionnaires
- PFDI - Colorectal Anal Distress
- PFDI - Pelvic Organ Prolapse Distress
- PFDI - Urinary Distress Inventory
- Shoulder Pain and Disability Index (SPADI)
- ABC Scale
- HOOS PS
- KOOS PS
- Freezing of Gait Questionnaire (FOGQ)
- Patient-Specific Functional Scale (PSFS)
- UEFI (Upper Extremity Functional Index)
- VAS Pain Scale
- Global Rating of Change (GROC)
- KOOS
- HOOS
- Fear Avoidance Belief Questionnaire (FABQ)
- Infection Management
- Falls Efficacy Scale - International (FES-I)
- Elderly Mobility Scale (EMS) Version 2
- Keele Musculoskeletal PROM
- The Rivermead Post-Concussion Symptom Questionnaire (RPQ)
- Health Leads Social Needs Screening Tool
- Lymphedema Life Impact Scale Version 2
- International Continence Society Questionnaire- Short form
- Pelvic Floor Distress Inventory (PFDI-20)
- Pelvic Floor Impact Questionnaire- (PFIQ-7)
- Modified Fatigue Impact Scale
- STaRT Back
Performance-Based
(These are internal facing- meaning patients will not see them on their tasks list to fill out. These should be completed by the therapist)
- Pediatric Balance Scale
- Timed up and Go Test (TUG)
- HiMAT: High Level Mobility Assessment Tool
- Functional Gait Assessment (FGA)
- Mini-Best (Mini Balance Evaluation Systems Test)
- BERG Balance Scale
- 30 second Sit to Stand
- Dynamic Gait Index
- Function in Sitting Test (FIST)
- 4-item Dynamic Gait Index (4-item DGI)
- The Cognitive Timed Up and Go
- The 10 Meter Walk Test
- The 5 time Sit to Stand
- The 6 Minute Walk Test