NCCN Distress Thermometer HomeNCCN Distress ThermometerGeneral Information Name * Required First Last Date of Birth * Required Day Month YearDate Completed * Required Day Month YearLevel of DistressPlease select the number (10=Extreme distress, 0= No distress) that best describes how much distress you have been experiencing in the past week, including today.Please select the number (10=Extreme distress, 0= No distress) that best describes how much distress you have been experiencing in the past week, including today. 10 9 8 7 6 5 4 3 2 1 0 Problem ListPlease indicate if any of the following has been a problem for you in the past week including today. Please select all that apply.Physical Problems Appearance Bathing/dressing Breathing Changes in urination Constipation Diarrhea Eating Fatigue Feeling swollen Fevers Getting around Indigestion Memory/concentration Mouth sores Nausea Nose dry/Congested Pain Sexual Skin dry/itchy Sleep Substance abuse Tingling in hands/feet Practical Problems Child care Housing Insurance/financial Transportation Work/school Treatment decisions Family Problems Dealing with children Dealing with partner Ability to have children Family health issues Emotional Problems Depression Fears Nervousness Sadness Worry Loss of interest in usual activities Spiritual/Religious concerns Spiritual/Religious concerns Other problems:Δ
