Symptom Assessment

Symptoms can be reported by the patient with the Symptom Assessment, which is a component of the Well-Being Assessment. There is a capability being developed tat will enable symptoms to be updated regularly via the well-being status. Symptoms are typically addressed by assigning Care Goals and interventions and activities in the Care Plan.

GENERAL SYMPTOMS ASSESSMENT

This is based on the Physical Symptoms (PHQ-15)

During the past 4 weeks, how much have you been bothered by any of the problems?

S1. Stomach pain?
□ Bothered a lot
□ Bothered a little
□ Not bothered at all

S2. Back pain?
□ Bothered a lot
□ Bothered a little
□ Not bothered at all

S3. Pain in your arms, legs, or joints (knees, hips, etc.)?
□ Bothered a lot
□ Bothered a little
□ Not bothered at all

S4. Menstrual cramps of other problems with your periods - WOMEN ONLY?
□ Bothered a lot
□ Bothered a little
□ Not bothered at all

S5. Headaches?
□ Bothered a lot
□ Bothered a little
□ Not bothered at all

S6. Chest pain?
□ Bothered a lot
□ Bothered a little
□ Not bothered at all

S7. Dizziness?
□ Bothered a lot
□ Bothered a little
□ Not bothered at all

S8. Fainting spells?
□ Bothered a lot
□ Bothered a little
□ Not bothered at all

S9. Feeling your heart pound or race?
□ Bothered a lot
□ Bothered a little
□ Not bothered at all

S10. Shortness of breath?
□ Bothered a lot
□ Bothered a little
□ Not bothered at all

S11. Pain or problems during sexual intercourse?
□ Bothered a lot
□ Bothered a little
□ Not bothered at all

S12. Constipation, loose bowels, or diarrhea?
□ Bothered a lot
□ Bothered a little
□ Not bothered at all

S13. Nausea, gas, or indigestion?
□ Bothered a lot
□ Bothered a little
□ Not bothered at all

PHQ-4. Feeling tired or having low energy?
□ Bothered a lot
□ Bothered a little
□ Not bothered at all

PHQ-3. Trouble failing or staying asleep, or sleeping too much?
□ Bothered a lot
□ Bothered a little
□ Not bothered at all