Patient Reported Outcome Form

Disease and Construct

Disease: *
Asthma Circadian rhythm COPD Excessive sleepiness Insomnia
Mental health Narcolepsy Pain Restless legs syndrome Sleep apnea
Sleep disturbances GERD Rhinitis Other
Construct: *
Quality of Life Symptoms Disease Severity Sleep quality

Outcome Questionnaires

Name of Measure: *
Description of Measure (1-2 sentence description): *
Validated in what age group (select an age group if the validation sample included even some of the age group): *
Preschool (0-5 years)
School age (6-12 years)
Teens (13-18 years)
Adults (18 + years)
Older Adults (65+)
Validity (construct, content, criterion, convergent, discriminant, predictive, consequential):
Reliability (internal consistency, test-retest, inter-observer):
Item Response Theory:
Minimally Important Difference Identified:
Computer adapted testing
Number of Subscales (List names)
Number of Items:
Item Response Scale (e.g. 0-4 Likert):
Alternate Versions Available:
Scoring instructions if available:
Languages Available:
Developer Name:
Developer Email:
Developer Contact Info (address to contact):
Permission Needed:
Contact for Permission:
Reference to Original Publication: *

Submitter Information

Updated By (name): *
Updated By (email): *