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17

NCCN Guidelines for Patients

®

:

Distress, Version 1.2017

2

How distressed are you?

Screening benefits

Please indicate if any of the following has been a problem for you in the past week including today. Be sure to

check YES or NO for each.

Problem List

Other Problems

:

YES NO Practical Problems

 

Child care

 

Housing

 

Insurance/financial

 

Transportation

 

Work/school

 

Treatment decisions

Family Problems

 

Dealing with children

 

Dealing with partner

 

Ability to have children

 

Family health issues

Emotional Problems

 

Depression

 

Fears

 

Nervousness

 

Sadness

 

Worry

 

Loss of interest in

usual activities

 

Spiritual/religious

concerns

YES NO Physical Problems

 

Appearance

 

Bathing/dressing

 

Breathing

 

Changes in urination

 

Constipation

 

Diarrhea

 

Eating

 

Fatigue

 

Feeling swollen

 

Fevers

 

Getting around

 

Indigestion

 

Memory/concentration

 

Mouth sores

 

Nausea

 

Nose dry/congested

 

Pain

 

Sexual

 

Skin dry/itchy

 

Sleep

 

Substance abuse

 

Tingling in hands/feet