Cancer Concerns Checklist

This self assessment it will help us understand the concerns and feelings you have. It will also help us identify any information and support you may need.

Cancer Concerns Checklist

Patient Details

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.

Physical Concerns

Practical Concerns

Emotional Concerns

Family or Relationship Concerns

Spiritual Concerns

Information or Support