NCCN Distress Thermometer & Problem List

PROBLEM LIST

Please 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 Problems
• Child care*
  • Yes
  • No
• Housing*
  • Yes
  • No
• Insurance/financial*
  • Yes
  • No
• Transportation*
  • Yes
  • No
• Work/school*
  • Yes
  • No
• Treatment decisions*
  • Yes
  • No
• YES / NO Family Problems
• Dealing with children*
  • Yes
  • No
• Dealing with partner*
  • Yes
  • No
• Ability to have children*
  • Yes
  • No
• Family health issues*
  • Yes
  • No
• YES / NO Emotional Problems
• Depression*
  • Yes
  • No
• Fears*
  • Yes
  • No
• Nervousness*
  • Yes
  • No
• Sadness*
  • Yes
  • No
• Worry*
  • Yes
  • No
• Loss of interest in usual activities*
  • Yes
  • No
• Spiritual/religious concerns*
  • Yes
  • No
• YES / NO Physical Problems
• Appearance*
  • Yes
  • No
• Bathing/dressing*
  • Yes
  • No
• Breathing*
  • Yes
  • No
• Changes in urination*
  • Yes
  • No
• Constipation*
  • Yes
  • No
• Diarrhea*
  • Yes
  • No
• Eating*
  • Yes
  • No
• Fatigue*
  • Yes
  • No
• Feeling swollen*
  • Yes
  • No
• Fevers*
  • Yes
  • No
• Getting around*
  • Yes
  • No
• Indigestion*
  • Yes
  • No
• Memory/concentration*
  • Yes
  • No
• Mouth sores*
  • Yes
  • No
• Nausea*
  • Yes
  • No
• Nose dry/congested*
  • Yes
  • No
• Pain*
  • Yes
  • No
• Sexual*
  • Yes
  • No
• Skin dry/itchy*
  • Yes
  • No
• Sleep*
  • Yes
  • No
• Substance use*
  • Yes
  • No
• Tingling in hands/feet*
  • Yes
  • No