Skip to content
Search for:
How Are You Doing?
Hidden
Name
First
Last
Where are you in your cancer journey?
*
I am a person with cancer going through cancer treatment.
I am a person with cancer raising children (under age 19).
I am a person no longer in active cancer treatment.
I am a person worried about my cancer risk (Previvor).
I am supporting someone who is actively going through cancer treatment.
I am supporting someone who is no longer in active treatment.
I am a parent with a child diagnosed (under age 19).
l am grieving the loss of someone to cancer.
Living with Cancer
Cancer can make daily living more difficult. Rate how much difficulty you had managing this week, including today:
*
Rate on a scale from 0-10, where
0 = “No Difficulty”
and
10 = “A Lot of Difficulty”
.
0
1
2
3
4
5
6
7
8
9
10
What concerns made this week difficult for you, including today?
(Please check that apply.)
Child Care
Food
Housing/Utilities
Insurance/Financial
Transportation
Work/School
Irritability / Anger
Fears
Nervousness
Sadness
Worry
Loss of interest in usual activities
Isolation
Treatment Decisions
Interacting / talking with my children
Interacting / Concerns with my partner
The ability to have children
Family health issues
Spiritual / Religious
Physical side effects / challenges
Personal Safety
Do problems getting childcare make it difficult for you to work or study?
*
Yes
No
Are you eating less than you feel you should because there isn’t enough money for food?
*
Yes
No
Has the electric, gas, oil, or water companies threatened to shut off your services in your home?
*
Yes
No
Are you worried that in the next 2 months, you may not have stable housing?
*
Yes
No
Have you needed to see a doctor, but could not because of cost?
*
Yes
No
Has lack of transportation kept you from medical appointments, meetings, work, or getting things for daily living?
*
Yes
No
Do you ever need help reading hospital materials?
*
Yes
No
Physical Concerns
Any changes in symptoms onset or intensity should be addressed with your healthcare team.
Appearance
Bathing/dressing
Breathing
Changes in urination
Constipation
Diarrhea
Eating
Fatigue
Fevers
Getting around and staying active
Indigestion
Memory/Concentration
Mouth sores
Nausea
Nose dry/congested
Pain
Rash
Sexual
Sleep
Substance Abuse
Swelling of the Extremities
Skin dry/itchy
Tingling in hands/feet
Supporting a Loved One
Supporting a loved one through the cancer treatment journey can be very challenging. Rate how much difficulty you had managing this week, including today.
*
Rate on a scale from 0-10, where
0 = “No Difficulty”
and
10 = “A Lot of Difficulty”
.
0
1
2
3
4
5
6
7
8
9
10
What emotional challenges made this week difficult for you, including today?
(Check all that apply)
Irritability / Anger
Fears
Nervousness
Sadness
Worry
Loss of interest in usual activities
Balancing Responsibilities
Balancing your responsibilities for your own life with supporting a loved one with cancer can be tough. Over the last 2 weeks, how often do you feel your own wellbeing and lifestyle needs are met? Please indicate below:
I am able to take care of my own daily needs.
*
(Meals, personal hygiene, laundry, etc.)
Always
Frequently
Sometimes
Occasionally
Rarely
I am able to take care of home maintenance activities.
*
(Mowing the lawn, cleaning, repairs, etc.)
Always
Frequently
Sometimes
Occasionally
Rarely
I am able to participate in community events through my church, neighborhood, or other groups when I want to.
*
Always
Frequently
Sometimes
Occasionally
Rarely
I am able to take time for myself and have fun with my friends and family.
*
Always
Frequently
Sometimes
Occasionally
Rarely
I am able to treat myself or reward myself when I want to.
*
Always
Frequently
Sometimes
Occasionally
Rarely
I eat a well-balanced, healthy diet.
*
Always
Frequently
Sometimes
Occasionally
Rarely
I get enough sleep and feel well-rested.
*
Always
Frequently
Sometimes
Occasionally
Rarely
I feel like I get enough exercise.
*
Always
Frequently
Sometimes
Occasionally
Rarely
I feel confident and secure about my financial future.
*
Always
Frequently
Sometimes
Occasionally
Rarely
I feel good about myself.
*
Always
Frequently
Sometimes
Occasionally
Rarely
I feel appreciated by others.
*
Always
Frequently
Sometimes
Occasionally
Rarely
Grieving & Bereavement
Emotional challenges following the death of a loved one can make daily living more difficult. Rate how much difficulty you had managing this week, including today.
*
Rate on a scale from 0-10, where
0 = “No Difficulty”
and
10 = “A Lot of Difficulty”
.
0
1
2
3
4
5
6
7
8
9
10
What emotional challenges made this week difficult for you, including today?
(Please check all that apply.)
Irritability / Anger
Fears
Nervousness
Sadness
Worry
Loss of interest in usual activities
How much are you having trouble accepting the death of your loved one?
*
Not at all
Somewhat
A lot
How much does your grief interfere with your life?
*
Not at all
Somewhat
A lot
How much are you having images or thoughts of your loved one when they died or other thoughts about the death that really bother you?
*
Not at all
Somewhat
A lot
Are there things you used to do when your loved one was alive that you don’t feel comfortable doing anymore and avoid? How much are you avoiding these things?
*
(For example, going somewhere you went with them, doing things you used to enjoy together, looking at pictures of your loved one, or talking about your loved one.)
Not at all
Somewhat
A lot
How much are you feeling cut off or distant from other people since your loved one died – even people you used to be close to, like family or friends?
*
Not at all
Somewhat
A lot
Tell Us More
Over the past 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things
*
Not at All
Several Days
More than half the days
Nearly every day
Feeling down, depressed or hopeless
*
Not at All
Several Days
More than half the days
Nearly every day
Hidden
PHQ-2 SCORE
Coping
What do you do to cope or feel better about your symptoms and other challenges?
Δ
Page load link
