Page 104 - CPG - Clinical Practice Guidelines - Management of Cancer Pain

Name:
Date (dd/mm/yyyy):
Please write clearly, one letter or digit per box. Your answers will help us to keep
improving your care and the care of others.
Thank you.
Q1. What have been your main problems or concerns over the past week?
1.
2.
3.
Q2. Below is a list of symptoms, which you may or may not have experienced. For each symptom,
please tick one box that best describes how it has affected you over the past week.

Pain
4
3
2
2
4
3
Shortness of breath
3
0
2
4
Weakness or lack of energy
1
0
3
Nausea (feeling like you are going to be sick)
2
4
1
1
3
Vomiting (being sick)
2
4
0
2
Poor appetite
4
1
3
0
0
Constipation
4
3
2
1
1
0
3
4
Sore or dry mouth
2
1
0
Drowsiness
4
2
3
Poor mobility
4
1
2
3
0
Please list any other symptoms not mentioned above, and tick one box to show how they have
affected you over the past week.
2
3
0
4
1
1.
1
2
4
2.
3
0
3.
0
4
3
1
2
Over the past week: 0 0 Not at all 1 1 Slightly Moderately Severely Overwhelmingly
Not at all Occasionally Sometimes Most of the time Always
Q3. Have you been feeling anxious
or worried about your illness or 0 1 2 3 4
treatment?
Q4. Have any of your family or friends 0 1 2 3 4
been anxious or worried about you? Management of Cancer Pain (Second Edition)
Q5. Have you been feeling depressed? 0 1 2 3 4

Always Most of the time Sometimes Occasionally Not at all
Q6. Have you felt at peace? 0 1 2 3 4
Q7. Have you been able to share how
you are feeling with your family or 0 1 2 3 4
friends as much as you wanted?
Q8. Have you had as much information
as you wanted? 0 1 2 3 4
Problems
Problems Problems Problems Problems Problems
partly
addressed/ mostly partly hardly not
No problems addressed addressed addressed addressed
addressed
Q9. Have any practical problems
resulting from your illness been 0 1 2 3 4
addressed? (such as financial or
personal)
With help With help
from a from a
On my own a friend or member or
relative staff
Q10. How did you complete this
questionnaire?
If you are worried about any of the issues raised on this questionnaire
then please speak to your doctor or nurse.
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concerns which matter to a patient. There are 10 questions scored on a scale of
1-4, which assess a patient’s symptoms and needs with regards to physical, social,
psychological and spiritual.
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86
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