Can We Help You

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

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

Activities of Daily Living:
(Physical Impact)
1. Changes with your sleeping patterns?
  Sleeping more than usual
Sleeping less than usual
Difficulty falling asleep
Nightmares
Chronic fatigue
Other
   
2. Changes with your eating habits?
  Loss of appetite
Nausea/vomiting
Weight loss/gain
Difficulty swallowing
Feeding tube
Other
   
3. Changes with your hygiene/elimination?
  Diarrhea
Constipation
Incontinence
Difficulty with grooming
Difficulty bathing
Other
   
4. Changes with mobility?
  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?
  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?
  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?
  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?
   
3. Are you drinking alcohol more/less than you did before your diagnosis?
   
4. What are your primary sources of strength in times of stress?
 
   
5. Are you having difficulty coping at this time?
 
  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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