Supported Questionnaires

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. 

 

5 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