Study number _________________ Staff name_____________ Date ________________ POS no 1st□ 2nd□ 3rd□ 4th□ 5th□ 6th□
Ask the patient
Q1. Please rate your pain (from 0 = no pain to 5 worst/overwhelming pain) during the last 3 days
Q2. Have any other symptoms (e.g., nausea, coughing or constipation) been affecting how you feel in the last 3 days?
Q3. Have you been feeling worried about your illness the past 3 days?
Q4. Over the past 3 days, have you been able to share how you are feeling with your family or friends?
Q5. Over the past 3 days have you felt that life was worthwhile?
Q6. Over the past 3 days, have you felt at peace?
Q7. Have you had enough help and advice for your family to plan for the future?
Ask the family carer
Q8. How much information have you and your family been given?
Q9. How confident does the family feel caring for ____?
Q10. Has the family been feeling worried about the patient over the last 3 days?
Possible responses
A1. 0 (no pain)–5 (worst/overwhelming pain)  0 □ 1 □ 2 □ 3 □ 4 □ 5 □
A2. 0 (not at all)–5 (overwhelmingly)  0 □ 1 □ 2 □ 3 □ 4 □ 5 □
A3. 0 (not at all)–5 (overwhelming worry)  0 □ 1 □ 2 □ 3 □ 4 □ 5 □
A4. 0 (not at all)–5 (yes, I've talked freely)  0 □ 1 □ 2 □ 3 □ 4 □ 5 □
A5. 0 (no, not at all)–5 (yes, all the time)  0 □ 1 □ 2 □ 3 □ 4 □ 5 □
A6. 0 (no, not at all)–5 (Yes, all the time)  0 □ 1 □ 2 □ 3 □ 4 □ 5 □
A7. 0 (not at all)–5 (as much as wanted)  0 □ 1 □ 2 □ 3 □ 4 □ 5 □
A8. 0 (none)–5 (as much as wanted)    N/A □  0 □ 1 □ 2 □ 3 □ 4 □ 5 □
A9. 0 (not at all)–5 (very confident)     N/A □  0 □ 1 □ 2 □ 3 □ 4 □ 5 □
A10. 0 (not at all)–5 (severe worry)    N/A □  0 □ 1 □ 2 □ 3 □ 4 □ 5 □