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Staunton & Corse Surgery NHS GP Surgery in Gloucestershire

Cancer concerns checklist

Cancer Concerns Checklist

Section

Identifying your concerns

If any of the problems listed have caused you concern recently and you wish to discuss them with a key worker, please select the box and score the concern from 1 to 10, with 10 being the highest. Leave the box and score blank if it doesn’t apply to you or you don’t want to discuss it now.

I have questions about my diagnosis, treatments or effects

Rate 1-10:

Physical Concerns

Breathing difficulties

Rate 1-10:

Passing urine

Rate 1-10:

Constipation

Rate 1-10:

Diarrhoea

Rate 1-10:

Eating, appetite or taste

Rate 1-10:

Indigestion

Rate 1-10:

Swallowing

Rate 1-10:

Cough

Rate 1-10:

Sore or dry mouth or ulcers

Rate 1-10:

Nausea or vomiting

Rate 1-10:

Tired, exhausted or fatigued

Rate 1-10:

Swelling

Rate 1-10:

High temperature or fever

Rate 1-10:

Moving around (walking)

Rate 1-10:

Tingling in hands or feet

Rate 1-10:

Pain or discomfort

Rate 1-10:

Hot flushes or sweating

Rate 1-10:

Dry, itchy or sore skin

Rate 1-10:

Changes in weight

Rate 1-10:

Wound care

Rate 1-10:

Memory or concentration

Rate 1-10:

Sight or hearing

Rate 1-10:

Speech or voice problems

Rate 1-10:

My appearance

Rate 1-10:

Sleep problems

Rate 1-10:

Sex, intimacy or fertility

Rate 1-10:

Other medical conditions

Rate 1-10:

Practical Concerns

Taking care of others

Rate 1-10:

Work or education

Rate 1-10:

Money or finance

Rate 1-10:

Travel

Rate 1-10:

Housing

Rate 1-10:

Transport or parking

Rate 1-10:

Talking or being understood

Rate 1-10:

Laundry or housework

Rate 1-10:

Grocery shopping

Rate 1-10:

Washing and dressing

Rate 1-10:

Preparing meals or drinks

Rate 1-10:

Pets

Rate 1-10:

Difficulty making plans

Rate 1-10:

Smoking cessation

Rate 1-10:

Problems with alcohol or drugs

Rate 1-10:

My medication

Rate 1-10:

Emotional Concerns

Uncertainty

Rate 1-10:

Loss of interest in activities

Rate 1-10:

Unable to express feelings

Rate 1-10:

Thinking about the future

Rate 1-10:

Regret about the past

Rate 1-10:

Anger or frustration

Rate 1-10:

Loneliness or isolation

Rate 1-10:

Sadness or depression

Rate 1-10:

Hopelessness

Rate 1-10:

Guilt

Rate 1-10:

Worry, fear or anxiety

Rate 1-10:

Independence

Rate 1-10:

Family or Relationship Concerns

Partner

Rate 1-10:

Children

Rate 1-10:

Other relatives or friends

Rate 1-10:

Person who looks after me

Rate 1-10:

Person who I look after

Rate 1-10:

Spiritual Concerns

Faith or spirituality

Rate 1-10:

Meaning or purpose of life

Rate 1-10:

Feeling at odds with my culture, beliefs or values

Rate 1-10:

Information or Support

Exercise and activity

Rate 1-10:

Diet and nutrition

Rate 1-10:

Complementary therapies

Rate 1-10:

Planning for my future priorities

Rate 1-10:

Making a will or legal advice

Rate 1-10:

Health and wellbeing

Rate 1-10:

Patient or carer’s support group

Rate 1-10:

Managing my symptoms

Rate 1-10:

If you are human, leave this field blank.

Gloucester Road
Corse
Gloucester
Gloucestershire
GL19 3RB

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01452 840228

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