‫ﻧﻤﻮذج ﻓﺤﺺ أﻋﺮاض اﻟﺮﻋﺎﻳﺔ اﻟﺘﻠﻄﻴﻔﻴﺔ‬
‫_________________ :‪Patient Dx‬‬             ‫اﻟﺘﺸﺨﻴﺺ:‬                ‫اﻟﺘﺎرﻳﺦ:_____...
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Symptom Assessment Sheet Arabic

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Symptom Assessment Sheet Arabic

  1. 1. ‫ﻧﻤﻮذج ﻓﺤﺺ أﻋﺮاض اﻟﺮﻋﺎﻳﺔ اﻟﺘﻠﻄﻴﻔﻴﺔ‬ ‫_________________ :‪Patient Dx‬‬ ‫اﻟﺘﺸﺨﻴﺺ:‬ ‫اﻟﺘﺎرﻳﺦ:_____________ :‪Date‬‬ ‫اﻟﺮﻗﻢ:______________:#‪ID‬‬ ‫اﻟﻤﺮآﺰ:_____________ :‪Center Name‬‬ ‫أﺳﻮأ أﻟﻢ ﻣﻤﻜﻦ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫ﻻ ﻳﻮﺟﺪ أﻟﻢ‬ ‫أﺳﻮأ إﻋﻴﺎء ﻣﻤﻜﻦ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫ﻻ ﻳﻮﺟﺪ إﻋﻴﺎء‬ ‫أﺳﻮأ ﻏﺜﻴﺎن ﻣﻤﻜﻦ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫ﻻ ﻳﻮﺟﺪ ﻏﺜﻴﺎن‬ ‫أﺳﻮأ إﺣﺒﺎط ﻣﻤﻜﻦ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫ﻻ ﻳﻮﺟﺪ إﺣﺒﺎط‬ ‫أﺳﻮأ ﺗﻮﺗﺮ ﻣﻤﻜﻦ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫ﻻ ﻳﻮﺟﺪ ﺗﻮﺗﺮ‬ ‫أﺳﻮأ دوﺧﺔ ﻣﻤﻜﻨﺔ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫ﻻ ﻳﻮﺟﺪ دوﺧﺔ‬ ‫أﺳﻮأ ﺿﻴﻖ ﻧﻔﺲ ﻣﻤﻜﻦ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫ﻻ ﻳﻮﺟﺪ ﺿﻴﻖ ﻧﻔﺲ‬ ‫أﺳﻮأ ﺷﻬﻴﺔ ﻣﻤﻜﻨﺔ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫أﻓﻀﻞ ﺷﻬﻴﺔ ﻣﻤﻜﻨﺔ‬ ‫أﺳﻮأ ﻧﻮم ﻣﻤﻜﻦ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫أﻓﻀﻞ ﻧﻮم ﻣﻤﻜﻦ‬ ‫أﻓﻀﻞ ﺷﻌﻮر‬ ‫أﺳﻮأ ﺷﻌﻮر ﻣﻤﻜﻦ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫ﻣﻤﻜﻦ‬ ‫اﻟﻔﺎﺣﺺ:___________________ :‪Assessed by‬‬ ‫.‪Source: The University of Texas, MD Anderson Cancer Center‬‬ ‫00279 ‪733 Dr. Geminer St., Karkafa, Bethlehem –Palestine. P.O. Box: 19960 East Jerusalem‬‬ ‫‪Telefax: 972 2 2767337 , Mobile: 972 522495249 , E-mail: sadeelsoc@yahoo.com‬‬

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