Symptom Assessment Sheet

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Symptom Assessment Sheet

  1. 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

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