Assess your needs"*" indicates required fieldsMany people affected by a cancer diagnosis may need support with some or all of the things listed. Knowing what you need help with can be difficult. The Distress Thermometer helps you score the amount of worry or concern you may be experiencing at the moment. The Problem List helps identify the causes of those concerns or worries. You can complete the form download it and take it to your doctor, GP or nurse. You can also email the form to yourself or someone else.Instructions: Please click the number (0-10) that best describes how much distress you have been experiencing in the past week including today.If you score 4 or above we recommend you download a copy of the completed Thermometer and Problem List and take it with you to your next hospital or GP appointment. Ask your doctor or nurse to talk through the problems you have identified or you may want to call the Cancer Council Victoria 13 11 20 phone support line.A score of 7 or above suggests that you are experiencing a very high level of distress. It is important to seek support as soon as possible so that you get the help you need. Click here to find supports and resources.NCCN DISTRESS THERMOMETER* 10 9 8 7 6 5 4 3 2 1 0Please indicate if any of the following has been a problem for you in the past week including today. Be sure to tick YES or NO for each.YES / NO Practical ProblemsChild care* Yes NoFood* Yes NoHousing* Yes NoInsurance/financial* Yes NoTransportation* Yes NoWork/school* Yes NoTreatment decisions* Yes NoYES / NO Family ProblemsDealing with children* Yes NoDealing with partner* Yes NoAbility to have children* Yes NoFamily health issues* Yes NoYES / NO Emotional ProblemsDepression* Yes NoFears* Yes NoNervousness* Yes NoSadness* Yes NoWorry* Yes NoLoss of interest in usual activities* Yes NoSpiritual/religious concerns* Yes NoYES / NO Physical ProblemsAppearance* Yes NoBathing/dressing* Yes NoBreathing* Yes NoChanges in urination* Yes NoConstipation* Yes NoDiarrhea* Yes NoEating* Yes NoFatigue* Yes NoFeeling swollen* Yes NoFevers* Yes NoGetting around* Yes NoIndigestion* Yes NoMemory/concentration* Yes NoMouth sores* Yes NoNausea* Yes NoNose dry/congested* Yes NoPain* Yes NoSexual* Yes NoSkin dry/itchy* Yes NoSleep* Yes NoSubstance use* Yes NoTingling in hands/feet* Yes NoOther Problems:Saving and viewing optionsEmailWould you like this form to be emailed to you? YesEmail myselfThis address will be automatically deleted after the email has been sent. Saving and PrintingYou will also be able to save and print the form after clicking Continue below.Consent (required)* I have read the privacy statement.If you complete the form above and chose to email a copy to yourself, your email address will be stored on our site temporarily to enable this to happen. Your IP (internet) address is not collected with the form information. Data from completed forms is retained for University of Melbourne purposes. The information collected can in no way be used to identify you or connected to you as an individual. Please read our complete privacy statement.HiddenPractical Problems AnswerHiddenMedical Problems AnswerEmailThis field is for validation purposes and should be left unchanged.