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Psycho-Oncology

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Psycho-Oncology

Please fill in the form completely.

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Patient Information

Full Name *

Age *

Illness and Treatment Course

Your diagnosis

Date of diagnosis

Current or planned treatment

What you have been told about the current status of your illness

Reason for Seeking Support

What is the main reason you are seeking psychological support at this time?

Difficulties in the Past 2 Weeks

Which of the following have been difficult for you in the past 2 weeks?

Anxiety / worry

Sadness / low mood

Fear of disease progression or recurrence

Fears related to death or the future

Treatment-related anxiety

Sleep problems

Fatigue / low energy

Difficulty coping with pain or other physical symptoms

Difficulties related to body image or sexuality

Concerns about family or children

Difficulties with work, school, or finances

Concentration or attention difficulties

Other

Other

Psychological Distress Level

Overall psychological distress at present (0 = No distress — 10 = Very intense distress)

0

1

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4

5

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8

9

10

Impact on Daily Life

To what extent do your illness and treatment affect your daily life? (0 = Not at all — 10 = Very severely)

0

1

2

3

4

5

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7

8

9

10

Which areas are affected the most?

Work / school

Family life

Social life

Daily responsibilities

Physical activities

Sleep

Close relationships

Other

Other

Support System

From whom are you receiving support during your illness and treatment?

My spouse / partner

My children

My parents

Other family members

My friends

Work colleagues

My healthcare team

Support group / patient group

Spiritual / religious community

I currently have no one I receive regular support from

Other

Other

To what extent do you feel you can obtain emotional or practical support when you need it? (0 = I cannot obtain any support — 10 = I can obtain adequate support when I need it)

0

1

2

3

4

5

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8

9

10

Psychological History and Expectations

Have you previously received psychological or psychiatric support?

Yes

No

If yes, briefly state when and for what reason

In which area would you most like psychological support to help you?

I have read and understood the Information and Consent Text regarding the Provision of Remote Healthcare Services and hereby accept its terms.*

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