NCCN Distress Thermometer HomeNCCN Distress ThermometerGeneral Information Name * Required First Last Date of Birth * Required DD MM YYYYDate Completed * Required DD MM YYYYLevel 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.109876543210Problem 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/feetPractical Problems Child care Housing Insurance/financial Transportation Work/school Treatment decisionsFamily Problems Dealing with children Dealing with partner Ability to have children Family health issuesEmotional Problems Depression Fears Nervousness Sadness Worry Loss of interest in usual activitiesSpiritual/Religious concerns Spiritual/Religious concernsOther problems:
