1. PALLIATIVE CARE SYMPTOM ASSESSMENT
Patient Dx: _________________ Date: _____________
ID#:______________ Center Name: __________________
Worst Pain Imaginable 10 9 8 7 6 5 4 3 2 1 0 No Pain
Worst Fatigue Imaginable 10 9 8 7 6 5 4 3 2 1 0 No Fatigue
Worst Nausea Imaginable 10 9 8 7 6 5 4 3 2 1 0 No Nausea
Worst Depression No
10 9 8 7 6 5 4 3 2 1 0
Imaginable Depression
Worst Anxiety Imaginable 10 9 8 7 6 5 4 3 2 1 0 No Anxiety
Worst Drowsiness No
10 9 8 7 6 5 4 3 2 1 0
Imaginable Drowsiness
Worst Shortness of Breath No Shortness
10 9 8 7 6 5 4 3 2 1 0
Imaginable Of Breath
Worst Appetite
10 9 8 7 6 5 4 3 2 1 0 Best Appetite
Imaginable
Worst Sleep Imaginable 10 9 8 7 6 5 4 3 2 1 0 Best Sleep
Worst Feeling of Best Feeling
10 9 8 7 6 5 4 3 2 1 0
Wellbeing Imaginable Of Wellbeing
Assessed by: _______________
Source: The University of Texas, MD Anderson Cancer Center.
733 Dr. Geminer St., Karkafa, Bethlehem –Palestine. P.O. Box: 19960 East Jerusalem 97200
Telefax: 972 2 2767337 , Mobile: 972 522495249 , E-mail: sadeelsoc@yahoo.com