Cancer Care: Education & Support: Support Groups

Please complete the follow questionnaire if would like help in coping with your cancer diagnosis and treatment modalities:

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 Generalized weakness Difficulty getting in/out of car	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	Location of pain: Other
Summary For Physical:
	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: (Impact on you emotionally 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 EMAIL: kathy.yeatman-stock@pvhmc.org

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Pomona Valley Hospital Medical Center
1798 N. Garey Avenue | Pomona, California 91767
(909) 865-9500 | Contact Us