Items | Terms in the English version | Revised |
---|---|---|
What have been your main problems or concerns over the past 7 days? | No | |
Below is a list of symptoms, which you may or may not have experienced. For each symptom, please tick one box that best describes how it has affected you over the past 7 days. | Yes | |
1 | Pain | No |
2 | Shortness of breath | No |
3 | Weakness or lack of energy | Yes |
4 | Nausea (feeling like you are going to be sick) | No |
5 | Vomiting (being sick) | No |
6 | Poor appetite | No |
7 | Constipation | No |
8 | Sore or dry mouth | No |
9 | Drowsiness | No |
10 | Poor mobility | No |
Please list any other symptoms not mentioned above, and tick one box to show how they have affected you over the past 7 days. | Yes | |
Over the past 7 days: | ||
11 | Have you been feeling anxious or worried about your illness or treatment? | No |
12 | Have any of your family or friends been anxious or worried about you? | No |
13 | Have you been feeling depressed? | Yes |
14 | Have you felt at peace? | Yes |
15 | Have you been able to share how you are feeling with your family or friends as much as you wanted? | No |
16 | Have you had as much information as you wanted? | Yes |
17 | Have any practical problems resulting from your illness been addressed? (Such as financial or personal) | Yes |
How did you complete this questionnaire? | No |