Q7: Have you 0 1 2 3 4 No 0 been able to Yes 1 share how you are feeling with your family and friends as much as you wanted? Q8: Have you 0 1 2 3 4 No 0 had as much Yes 1 information as you wanted? Over the Past Week: Problems Problems Problems Problems Problems Intervention offered or addressed/ mostly partly hardly not provided? no problems addressed addressed addressed addressed Q9: Have any 0 1 2 3 4 No 0 practical Yes 1 problems resulting from your illness been addressed? (such as financial or personal) Health Care Living Organ None Intervention offered or Proxy Will Donation of provided? Oral Advance Directive Q10: check all 0 1 2 3 4 No 0 advance Yes 1 directives known to have been completed: Q11: How did you complete this questionnaire? On My Own With Help from a friend or relative With help from a member of staff If you are worried about any of the issues raised on this questionnaire then please speak to your doctor or nurse
Q7: Have you been able to share how you are feeling with your family and friends as much as you wanted? 0 1 2 3 4 No 0 Yes 1 Q8: Have you had as much information as you wanted? 0 1 2 3 4 No 0 Yes 1 Over the Past Week: Problems addressed/ no problems Problems mostly addressed Problems partly addressed Problems hardly addressed Problems not addressed Intervention offered or provided? Q9: Have any practical problems resulting from your illness been addressed? (such as financial or personal) 0 1 2 3 4 No 0 Yes 1 Health Care Proxy Living Will Organ Donation of Oral Advance Directive None Intervention offered or provided? Q10: check all advance directives known to have been completed: 0 1 2 3 4 No 0 Yes 1 Q11: How did you complete this questionnaire? On My Own With Help from a friend or relative With help from a member of staff If you are worried about any of the issues raised on this questionnaire then please speak to your doctor or nurse
IPOS-Patient-Version-03162017-Electronic.docx