Pomona Valley Hospital Medical Center :: Centers of Excellence :: Cancer Care Center :: Education & Support

If you have indicated a moderate or severe response on the above questions, or if you have other concerns, please feel free to speak with our licensed clinical social worker. You can contact her by phone or email:

Kathy Yeatman-Stock
Phone: 909.865.9958 • E-Mail: kathy.yeatman-stock@pvhmc.org

Contact Information: (Fields marked * are mandatory)
	Name: *		Email: *
	Phone: *		Date of Diagnosis: *

Activities of Daily Living: (Physical Impact)
1.	Changes with your sleeping patterns? Yes No
	Sleeping more than usual Sleeping less than usual	Difficulty falling asleep Nightmares		Chronic fatigue Other

2.	Changes with your eating habits? Yes No
	Loss of appetite Nausea/vomiting	Weight loss/gain Difficulty swallowing		Feeding tube Other

3.	Changes with your hygiene/elimination? Yes No
	Diarrhea Constipation	Incontinence Difficulty with grooming		Difficulty bathing Other

4.	Changes with mobility? Yes No
	Limited range of motion Difficulty getting in/out of car	Generalized weakness No longer athletic or active		Wheelchair/walker/cane

5.	Affecting your roles in the family? Yes No
	You are not able to care for yourself or other at home. I need assistance with activities of daily living? (housework, meals, etc.) Other

6.	Pain management issues? Yes No
	Current pain Chronic pain	Other Location of pain:

	Summary For Physical Impact:
	Based on your answers to the above questions, please indicate your level of concern regarding these physical changes:
	No concern Mild concern	Moderate concern Severe concern


Coping: (Emotional Impact and ways you handle stress)
1.	Have you been experiencing any of the following feelings? Yes No
	Sadness Anger/frustration	Anxiety/fears Worried about the future

2.	Have you experienced changes socially such as not seeing family/friends as often as you did prior to your diagnosis? Yes No

3.	Are you drinking alcohol more/less than you did before your diagnosis? More Less No Change

4.	What are your primary sources of strength in times of stress?


5.	Are you having difficulty coping at this time? Yes No

	Summary For Coping:
	Based on your answers to the above questions, please indicate your level of concern regarding your ability to cope:
	No concern Mild concern	Moderate concern Severe concern

	Please check any of the following services that you or your family may need assistance with at this time:
	Advance care planning (advance directives information, guidance with long-term care decisions) Community Resources information and referrals Assistance with coping Other

	Additional Information:




	If you have indicated a moderate or severe response on the above questions, or if you have other concerns, please feel free to speak with our licensed clinical social worker. You can contact her by phone or email: Kathy Yeatman-Stock Phone: 909.865.9958 • E-Mail: kathy.yeatman-stock@pvhmc.org

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