Symptom Assessment

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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.

SYMPTOMS ASSESSMENT

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

S1. During the past 4 weeks, how much have you been bothered by stomach pain?
□ Bothered a lot
□ Bothered a little
□ Not bothered at all

S2. During the past 4 weeks, how much have you been bothered by back pain? □ Bothered a lot □ Bothered a little □ Not bothered at all


S3. During the past 4 weeks, how much have you been bothered by pain in your arms, legs, or jopints (knees, hips, etc.)? □ Bothered a lot □ Bothered a little □ Not bothered at all

1. During the past 4 weeks, how much have you been bothered by stomach pain? □ Bothered a lot □ Bothered a little □ Not bothered at al


1. During the past 4 weeks, how much have you been bothered by stomach pain? □ Bothered a lot □ Bothered a little □ Not bothered at all

1. During the past 4 weeks, how much have you been bothered by stomach pain? □ Bothered a lot □ Bothered a little □ Not bothered at al


1. During the past 4 weeks, how much have you been bothered by stomach pain? □ Bothered a lot □ Bothered a little □ Not bothered at all

1. During the past 4 weeks, how much have you been bothered by stomach pain? □ Bothered a lot □ Bothered a little □ Not bothered at al


1. During the past 4 weeks, how much have you been bothered by stomach pain? □ Bothered a lot □ Bothered a little □ Not bothered at all

1. During the past 4 weeks, how much have you been bothered by stomach pain? □ Bothered a lot □ Bothered a little □ Not bothered at al


1. During the past 4 weeks, how much have you been bothered by stomach pain? □ Bothered a lot □ Bothered a little □ Not bothered at all

1. During the past 4 weeks, how much have you been bothered by stomach pain? □ Bothered a lot □ Bothered a little □ Not bothered at al

1. During the past 4 weeks, how much have you been bothered by stomach pain? □ Bothered a lot □ Bothered a little □ Not bothered at all

1. During the past 4 weeks, how much have you been bothered by stomach pain? □ Bothered a lot □ Bothered a little □ Not bothered at al


1. During the past 4 weeks, how much have you been bothered by stomach pain? □ Bothered a lot □ Bothered a little □ Not bothered at all

1. During the past 4 weeks, how much have you been bothered by stomach pain? □ Bothered a lot □ Bothered a little □ Not bothered at al


1. During the past 4 weeks, how much have you been bothered by stomach pain? □ Bothered a lot □ Bothered a little □ Not bothered at all

1. During the past 4 weeks, how much have you been bothered by stomach pain? □ Bothered a lot □ Bothered a little □ Not bothered at al

Tobacco Use 4. In the last 30 days, have you used tobacco? □ yes □ no

Alcohol Use 7. In the past 7 days, how many days did you drink alcohol? □ 6 or 7 days □ 4 or 5 days □ 2 or 3 days □ 1 day □ none

Nutrition 10. In the past 7 days, how many servings of fruit and vegetables do you eat per day? (1 serving = 1 cup fresh vegetables, ½ cup cooked vegetables, or 1 medium piece of fruit. 1 cup = size of a baseball) □ 6 or more servings per day □ 4 or 5 servings per day □ 2 to 3 servings per day □ 1 serving per day □ none

11. In the past 7 days, how many servings of high fiber or whole grains food do you eat per day? (1 serving = 1 slice of 100% whole wheat bread, 1 cup of whole-grain or high-fiber ready-to-eat cereal, ½ cup of cooked cereal such as oatmeal, or ½ cup of brown rice or whole wheat pasta) □ 6 or more servings per day □ 4 or 5 servings per day □ 2 to 3 servings per day □ 1 serving per day □ none

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