Version May 2024
| The answers to the questions are intended to be quantified (scale 0 to 10) with the PEACE Tool Distress Thermometer. | ||||||
| In the past week, how much have you been bothered by or suffered from: | Date/Initials | |||||
| 1. Pain | ||||||
| 2. Appetite loss | ||||||
| 3. Incontinence of bladder or bowel | ||||||
| 4. Nausea, vomiting, constipation, or other bowel problems | ||||||
| 5. Breathing problems or cough | ||||||
| 6. Ulcers, dryness, or mouth sores | ||||||
| 7. Lesser (diminishing) ability to carry out daily activities and functions (cleaning, showering, lifting, walking, etc) | ||||||
| 8. Feeling weak or tired or having low energy | ||||||
| 9. Feeling sleepy during day and/or not sleeping at night | ||||||
| 10. Feeling anxious, nervous, uneasy, tense, or frightened | ||||||
| 11. Feeling sad, depressed, helpless, or unable to enjoy things | ||||||
| 12. Feeling confused, restless, or agitated | ||||||
| 13. Feeling not in control of your care and/or not being understood what you want | ||||||
| 14. Feeling not prepared for and/or fearing what is still ahead of you | ||||||
| 15. Feeling more need for support than your family, friends or insurance can provide | ||||||
| 16. Feeling abandoned or punished by God or not supported by your church/faith | ||||||
| From the list above, which problem are you suffering the most? | ||||||
| From the list above, which problem are you suffering the second most? | ||||||
| Notes (are there any other problems that have bothered you recently?)
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آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
