London Holistic Needs Assessment For each item below, please select yes or no if they have been a concern for you during the last week, including today. Please also select discuss if you wish to speak about it with your health professional. Choose not to complete the assessment today by selecting this box Date: Practical concerns Yes No Discuss Physical concerns Yes No Discuss Bathing or dressing Breathlessness Caring responsibilities Name: Changes in taste Difficulty making plans Changes in weight Grocery shopping Hospital/NHS Communication Housing or finances number: Constipation or diarrhoea Information needs Cough Please select the number that best describes Laundry/housework Dry, itchy or sore skin the overall level of distress you have been Preparing food feeling during the last week, including today: Eating or appetite Transport or parking Fatigue 10 Work or education Feeling swollen Family concerns 9 High temperature Relationship with children 8 Hot flushes Relationship with partner 7 Indigestion Relationship with others 6 Moving around/walking 5 Emotional concerns Nausea and/or vomiting 4 Anger, frustration or guilt Other medical condition 3 Hopelessness Pain 2 Loneliness or isolation Passing urine 1 Memory or concentration Personal appearance 0 Sadness or depression Sleep problems Sexual concerns Sore or dry mouth Worry, anxiety or fear Tingling in hands or feet For health professional use Spiritual concerns Wound care Date of Loss of faith or other spiritual concern diagnosis: Diagnosis: Loss of meaning or purpose in life Pathway point: Regret about the past Adapted with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Distress Management (V.2.2013). © 2013 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc." With thanks to Macmillan Cancer Support. LC/LCA_v2.0_2013.
London Holistic Needs Assessment For each item below, please select yes or no if they have been a concern for you during the last week, including today. Please also select discuss if you wish to speak about it with your health professional. Choose not to complete the assessment today by selecting this box Date: Practical concerns Yes No Discuss Physical concerns Yes No Discuss Bathing or dressing Breathlessness Name: Caring responsibilities Changes in taste Difficulty making plans Changes in weight Hospital/NHS number: Grocery shopping Communication Housing or finances Constipation or diarrhoea Please select the number that best describes the overall level of distress you have been feeling during the last week, including today: Information needs Cough Laundry/housework Dry, itchy or sore skin Preparing food Eating or appetite Transport or parking Fatigue 10 Work or education Feeling swollen 9 Family concerns High temperature 8 Relationship with children Hot flushes 7 Relationship with partner Indigestion 6 Relationship with others Moving around/walking 5 Emotional concerns Nausea and/or vomiting 4 Anger, frustration or guilt Other medical condition 3 Hopelessness Pain 2 Loneliness or isolation Passing urine 1 Memory or concentration Personal appearance 0 Sadness or depression Sleep problems Sexual concerns Sore or dry mouth Worry, anxiety or fear Tingling in hands or feet For health professional use Spiritual concerns Wound care Date of diagnosis: Loss of faith or other spiritual concern Diagnosis: Loss of meaning or purpose in life Pathway point: Regret about the past Adapted with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Distress Management (V.2.2013). © 2013 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and illustrations herein may not be reproduced in any form for any purpose without the express written permission of the NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org. NATIONAL COMPREHENSIVE CANCER NETWORK®, NCCN®, NCCN GUIDELINES®, and all other NCCN Content are trademarks owned by the National Comprehensive Cancer Network, Inc." With thanks to Macmillan Cancer Support. LC/LCA_v2.0_2013.