Table 1.
Items in the Community-Based Palliative Care Screening Tool.16
| Physical symptoms |
| Feeling tired or fatigued |
| Low energy |
| Difficulty sleeping (sleeping too much or can’t sleep) |
| Pain or physical discomfort |
| Difficulty standing or walking |
| Shortness of breath |
| Emotional concerns |
| Feeling nervous, anxious, or on edge |
| Not being able to stop or control worrying |
| Having little interest or pleasure in usual activities |
| Feeling down, depressed, or hopeless |
| Feeling overwhelmed about any medical treatment |
| Feeling a loss of meaning or purpose in your life at the moment |
| Worried about being dependent, or a burden on friends of family |
| Feeling like there is no one in your life whom you can talk to |
| Having conflicts with friends or family |
| Goals of care |
| Feeling confused about your medical care |
| Feeling uncomfortable asking questions about your care |
| Feeling like you want more support with your medical care |
| Feeling like you need access to more medical providers |
| Feeling like you need more information about available providers |
| Have you given thought to how you want to be cared for when your illness(es) advance? |
| Have you talked with anyone about how you want to be cared for? |
| Do you have a document that indicates what your wishes are and who will make decisions for you? |
| Do you have a Health Care Proxy? Have you completed a Living Will? |