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This form helps us understand your current state of health and how you’re feeling.

All information you provide on this form is kept confidential.

Tell us about your past 3 days - patients, family and staff may use this form

Name(Required)
DD slash MM slash YYYY

Below is a list of symptoms, which you may or may not have experienced. For each symptom, please tick one box that best describes how it has affected you over the past 3 days.

Pain
Shortness of breath
Weakness or lack of energy
Vomiting (being sick)
Nausea (feeling like you're going to be sick)
Poor appetite
Constipation
Sore or dry mouth
Drowsiness
Poor mobility

Please answer the following questions based on the past 3 days.

Have you been feeling anxious or worried about your treatment?(Required)
Have any of your family or friends been anxious or worried about you?(Required)
Have you been feeling depressed?(Required)
Have you felt at peace?(Required)
Have you been able to share how you are feeling with your family or friends as much as you wanted?(Required)
Have you had as much information as you wanted?(Required)
Have any practical problems resulting from your illness been addressed? (such as financial or personal)(Required)
How did you complete this questionnaire?(Required)

If you are worried about any of the issues raised in this questionnaire, please speak to one of the Waipuna Hospice team.

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