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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