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.

Confirmation

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:

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Section

Identifying your concerns

Physical Concerns

Practical Concerns

Emotional Concerns

Family or Relationship Concerns

Spiritual Concerns

Information or Support