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Patient Distress Checklist

Some distress is normal, but how much?

People may feel anxious, sad, fearful, or overwhelmed when they learn they have cancer. These, along with many other emotions, are normal responses that may last from a few days to a few weeks.

Sometimes these feelings drag on, and even get worse over time. This distress can last for months or longer. It can keep people from enjoying life and doing things that are important to them. This makes coping with cancer much, much harder. But help is available for those who ask for it.

“Do I Need Professional Support?” Self-Assessment Questionnaire for Patients

The following questionnaire may help you figure out whether professional counseling might be helpful to you. Every patient has some of these symptoms. Circle the answer that fits best for you, from 1 (not at all) to 5 (all the time) or one of the numbers in between. There are no right or wrong answers. Answer the questions honestly. If you try to cover up how you feel, you might not get the help you need.

During the past 2 weeks:

I have felt anxious or worried about cancer and the treatment I am receiving.

Not at all

1

2

3

4

5

All the time

I have felt depressed or discouraged.

Not at all

1

2

3

4

5

All the time

I have been irritable or unusually angry and I have not controlled it well.

Not at all

1

2

3

4

5

All the time

My sleeping habits have changed.

Not at all

1

2

3

4

5

All the time

I have noticed a change in my appetite.

Not at all

1

2

3

4

5

All the time

I have had trouble focusing at work or at home, or on routine things such as reading the newspaper or watching television.

Not at all

1

2

3

4

5

All the time

Cancer and its treatment have interfered with my daily activities.

Not at all

1

2

3

4

5

All the time

Cancer and its treatment have interfered with my family or social life.

Not at all

1

2

3

4

5

All the time

Cancer and its treatment have interfered with my sex life.

Not at all

1

2

3

4

5

All the time

Pain and discomfort have caused me to limit my activities.

Not at all

1

2

3

4

5

All the time

Cancer has caused physical, emotional, or financial hardship for me.

Not at all

1

2

3

4

5

All the time

Cancer and its treatment have caused changes in how I look, and this concerns me.

Not at all

1

2

3

4

5

All the time

I have had trouble coping with the stress I have been having.

Not at all

1

2

3

4

5

All the time

My quality of life during the past 2 weeks has been:

Excellent

1

2

3

4

5

Very poor

If you find that many of your answers are 4s or 5s, you may be having serious distress and should think about talking with a counselor or other mental health professional.

Source: Developed by the Department of Psychosocial Resources, Tom Baker Cancer Centre, and the Division of Psychosocial Oncology, Department of Oncology, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada. Derived in part from the Functional Living Index: Cancer, and from the EORTC Core Quality of Life Questionnaire. Published with permission.

Now what?

If you have symptoms that are severe enough to interfere with normal day-to-day life, see a doctor or mental health professional. It is very important to see a doctor if you are not coping with the illness, have thought about stopping treatment, or have missed medical appointments. You may want to print out this checklist and discuss it with your doctor, nurse, social worker, or someone else on your cancer care team.

It may also help to get more information on coping with cancer, how to talk with your family and loved ones about cancer, and how to find a support group. Look for help managing worries so they don’t stop you from feeling as well as you can. ACS support programs are available for cancer survivors and patients throughout the US. Practical advice is available online to help patients manage day-to-day and cope with physical and emotional changes. At the ACS Cancer Survivors Network Web site you can trade information and experiences with other patients and survivors—all without leaving home.

For more information call your American Cancer Society at 1-800-227-2345, or visit our Web site.

For more information on distress, see our document called Distress in People with Cancer.


Last Medical Review: 10/18/2011
Last Revised: 10/18/2011