609-537-6363

609-537-6363

Distress Management

Distress is an unpleasant experience of a mental, physical, social or spiritual nature. It can affect the way you think, feel, or act. Distress may make it harder to cope with having cancer, its symptoms, or its treatment.

Please complete the below in its entirety and your care team will use as a guide for support services.

Patient Name
Date of Birth
Please select the number (0-10) that best describes how much distress you have been experiencing in the past week, including today.
No Distress Extreme Distress
1 2 3 4 5 6 7 8 9 10
Have you had concerns about any of the items below in the past week, including today? (select all that apply) *
MENTAL HEALTH
FAITH OR RELIGION
PRODUCTIVITY
RELATIONSHIPS
PHYSICAL HEALTH
MEDICAL
Other Concerns