Symptom Assessment Sheet

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Al-Sadeel Society

Santé & Médecine

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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Symptom Assessment Sheet

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

Symptom Assessment Sheet

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