Gray Areas for Staff Completion Only Patient Name: Patient ID #: Palliative Care Agency Name: Palliative Care Representative Name: Assessment Date: Setting (check): Patient’s Home Office Nursing Home Telephone Assessment Type (check): Initial Status Change Routine Primary Insurance Type (check): Commercial Medicaid Medicare Uninsured Secondary Insurance Type (check): Commercial Medicaid Medicare Uninsured Q1. What have been your main problems or concerns over the past week? 1 2 3 Q2. Below is a list of symptoms, which you may or may not have experienced. For each symptom, please check one box that best describes how it has affected you over the past week. STAFF COMPLETED Symptom Not at Slightly Moderately Severely Intervention offered or All provided? Pain 0 1 2 3 4 No 0 Yes 1 Shortness of 0 1 2 3 4 No 0 breath Yes 1 Weakness or 0 1 2 3 4 No 0 lack of energy Yes 1 Nausea (feeling 0 1 2 3 4 No 0 like you are Yes 1 to be sick/vomiting) Vomiting (being 0 1 2 3 4 No 0 sick) Yes 1 Poor appetite 0 1 2 3 4 No 0 Yes 1 Constipation 0 1 2 3 4 No 0 Yes 1 Sore or dry 0 1 2 3 4 No 0 mouth Yes 1 Drowsiness 0 1 2 3 4 No 0 (sleepiness) Yes 1 Poor Mobility 0 1 2 3 4 No 0 (trouble walking, Yes 1 cannot leave bed, falling)
Gray Areas for Staff Completion Only Patient Name: Patient ID #: Palliative Care Agency Name: Palliative Care Representative Name: Assessment Date: Setting (check): Patient’s Home Office Nursing Home Telephone Assessment Type (check): Initial Status Change Routine Primary Insurance Type (check): Commercial Medicaid Medicare Uninsured Secondary Insurance Type (check): Commercial Medicaid Medicare Uninsured Q1. What have been your main problems or concerns over the past week? 1 2 3 Q2. Below is a list of symptoms, which you may or may not have experienced. For each symptom, please check one box that best describes how it has affected you over the past week. STAFF COMPLETED Symptom Not at All Slightly Moderately Severely Intervention offered or provided? Pain 0 1 2 3 4 No 0 Yes 1 Shortness of breath 0 1 2 3 4 No 0 Yes 1 Weakness or lack of energy 0 1 2 3 4 No 0 Yes 1 Nausea (feeling like you are to be sick/vomiting) 0 1 2 3 4 No 0 Yes 1 Vomiting (being sick) 0 1 2 3 4 No 0 Yes 1 Poor appetite 0 1 2 3 4 No 0 Yes 1 Constipation 0 1 2 3 4 No 0 Yes 1 Sore or dry mouth 0 1 2 3 4 No 0 Yes 1 Drowsiness (sleepiness) 0 1 2 3 4 No 0 Yes 1 Poor Mobility (trouble walking, cannot leave bed, falling) 0 1 2 3 4 No 0 Yes 1
IPOS-Patient-Version-03162017-Electronic.docx