Patient-Reported Information & Symptom Measurement (PRISM)
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- Gwen Peters
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1 Patient-Reported Information & Symptom Measurement (PRISM) Please answer the following questions to help us get to know you better. Your answers will help us provide you with the best care possible. This information will become part of your health record and will be available to your health care team. Please feel free to leave any questions blank that you do not wish to answer. Completed by: Patient Caregiver Nurse Other Date General Information 1. What gender do you identify with? Female Male Transgender woman Transgender man Other 2. What is your sexual orientation? Heterosexual/Straight Lesbian/Gay Bisexual Queer Other Not sure 3. a) Do you identify as an indigenous person? No Yes If yes, are you (please check) First Nations Metis Inuit Do you currently reside on your traditional territory? No Yes b) If no, to which ethnic or cultural group do you belong? White South Asian (e.g., East Indian, Pakistani, Sri Lankan, etc) Chinese Black Filipino Latin American Arab Southeast Asian (e.g., Vietnamese, Cambodian, Laotian, Thai, etc) West Asian (e.g., Iranian, Afghan, etc) Korean Japanese Other c) Which is your preferred language? d) Do you have any personal/cultural/ethnic/religious background that we need to know and respect? No Yes; please specify: Revised February /
2 Medical Information 4. What is your marital status? Single Married/Common-law/Living with Partner Divorced/Separated Widowed Living alone Living with support person 5. Do you have dependents (children or adults) living at home with you? No Yes 6. Are you currently employed? No Yes Self-employed 7. What is/was your occupation? 8. Do you have a drug plan that helps to pay for medication? No Yes Don t know 9. Are you receiving one or both of these professional services at home? Homemaking Services Home Care Nursing 10. Do you have any issues regarding transportation to the cancer centre? No Yes 11. Do you have a family (blood relatives) history of cancer? No Yes Don t know _If you have a family history of cancer, please list who in your family has or had cancer and the type of cancer: Family Member Type of Cancer 12. Do you have any allergies? No Yes Don t know If yes, please indicate the type of allergy you have and your reaction to the allergy in the table below: Allergy (for example: medication, latex, other) Reaction 2/ Revised February 2018
3 Medical Information 13. Please indicate if you have or had any of the following (please check all that apply): Heart & Vascular: Heart problems, e.g. heart attacks, abnormal heart rate High blood pressure Blood clots Stroke Implanted electronic/ magnetic device, e.g. pacemaker, neurostimulator, insulin pump, defibrillator Lung: Asthma/emphysema/COPD Tuberculosis (TB) Kidney: Kidney disease Dialysis Liver: Hepatitis Cirrhosis Mental Health: Depression Anxiety Claustrophobia Other, please specify _ mental health concerns: Joints & Muscles: Arthritis Connective tissue disorder, e.g. Lupus, Scleroderma Joint replacement General: Menopause: age when your menstrual period stopped Number of pregnancies: Number of live births: Currently pregnant Date of last menstrual period: Diabetes HIV/AIDS Other cancer diagnosis: Previous radiation therapy: Past operations, please list: Other: Revised February /
4 14. Have you ever been told you had a multi-resistant organism, drug resistant organism, MRSA, VRE, CRE, or Super Bug? Don t know No Yes 15. Please circle the number that best describes your level of activity: 0 Usual activity no problem 1 Mild able to continue normal activity 2 Change in normal activity bed rest less than 50% waking hours 3 In bed/chair more than 50% waking hours 4 Bed/chair ridden or unable to care for self 16. Do you have any balance/muscle weakness problems? No Yes 17. Have you fallen in the last 6 months? No Yes 18. Do you use a cane, walker or wheelchair? No Yes 19. Have you ever smoked tobacco? No Yes If yes, a) How long has it been since you last smoked a cigarette (even one or two puffs) I smoked today 1-7 days (number of days since last cigarette) Less than one month (number of weeks since last cigarette) Less than one year (number of months since last cigarette) More than one year (number of years since last cigarette) b) How old were you when you started smoking regularly? years old c) On average, how many cigarettes do you or did you smoke per day? d) How soon after you wake up do you or did you usually smoke your first cigarette of the day? Within the first hour Usually after the first hour 20. Do you currently smoke other products or chew tobacco? No Yes If yes, please describe: 21. Do you use Cannabis products in any form? No Yes If yes, please describe: 22. Do you use recreational/street drugs other than Cannabis? No Yes If yes, please describe: 23. Do you drink beer, wine or other alcoholic beverages? No Yes If yes, how many drinks would you have in a week? 4/ Revised February 2018
5 Wishes or Plans for Health Care Advance Care Planning is a process by which adults talk over their beliefs, values and wishes for health care with their close family/friend(s) and health care providers in advance of a time when they may not be able to decide for themselves. 1) I know about Advance Care Planning: No Yes Not Sure 2) If yes, do you have wishes and plans for your health care written down? No Yes* Not Sure * If yes, please share a copy with us so that we can understand your wishes and instructions. 3) If you answered no to question 2, would you like to discuss this with someone on the healthcare team? No Yes Not Sure 4) I would like more information about Advance Care Planning. No Yes Not Sure Revised December 05, 2017 November 06, /
6 Symptom Self Assessment Please circle the number that best describes how you feel NOW: No pain Worst possible pain No tiredness (Tiredness = lack of energy) No drowsiness (Drowsiness = feeling sleepy) Worst possible tiredness Worst possible drowsiness No nausea Worst possible nausea No lack of appetite Worst possible lack of appetite No shortness of breath Worst possible shortness of breath No depression Worst possible depression No anxiety (Anxiety = feeling nervous) Best feeling of wellbeing (Wellbeing =how you feel overall) Worst possible anxiety Worst possible wellbeing No other problem (for example, constipation) Worst possible 6/ * Adapted from the Edmonton Symptom Assessment System (ESAS) with permission
7 PSSCAN-R Psychological Screening Please answer the following questions to help us learn more about your well being. A serious illness can affect the quality of your life in many ways. We may contact you to offer our counselling services based on the information you provide to us, or contact you regarding opportunities to participate in research. Part A: Please respond to each question with Yes or No by making a circle around the appropriate answer. There are no right or wrong answers. 1. Do you live alone? No Yes 2. When you need help, can you count on anyone to help with daily tasks such as grocery shopping, cooking, giving you a ride? No Yes 3. Do you have regular contact with friends or relatives? No Yes 4. Have you lost your life partner within the last few years? No Yes 5. Can you count on anyone to provide you with emotional support? No Yes Part B: Please check all of the following items that have been of concern or a problem for you in the past week including today.* 6. Emotional: Fears/Worries Sadness Frustration/Anger Changes in appearance Intimacy/Sexuality 8. Practical: Work/School Finances Getting to & from appointments Accommodation 10. Social/Family: Feeling a burden to others Worry about family/friends Feeling alone 7. Informational: Understanding my illness/treatment Talking with the health care team Making treatment decisions Knowing about available resources 9. Spiritual: Meaning/Purpose of life Faith 11. Physical: Concentration/Memory Sleep Weight Other concerns, please specify: * Canadian Problem Checklist developed by the Canadian Partnership Against Cancer, August Revised April 2014 Please see over > 7/
8 Part C: Please place an X in the box that best describes what you have experienced. 12. During the past week I have felt my heart race and I tremble. 13. During the past week I have felt that I cannot control anything. 14. During the past week I have lost interest in things I usually cared for or enjoyed. 15. During the past week I have felt nervous and shaky inside. 16. During the past week I have felt tense and cannot relax. 17. During the past week my thoughts are repetitive and full of scary things. 18. During the past week I have felt restless and find it difficult to sit still. 19. I have recently thought about taking my life. NOTE: If you have, please speak with a member of your health care team and/or your family doctor today. 20. In the past year, I have had 2 weeks or during which I felt sad, blue or depressed. 21. I have had 2 years or more in my life when I felt depressed or sad most days even if I felt okay sometimes. Not at all A little bit Moderately Quite a bit Very much Thank you for taking the time to respond to this form. If you or your family is currently struggling with the stress of your diagnosis, information and support is available on our website: or by calling: BC Cancer Patient & Family Counselling Departments Abbotsford Kelowna Prince George Surrey Vancouver x Victoria Patient and Family Counselling Documentation: D = A = Comments: Reviewed by: Date: 8/ Revised April 2014 Review May 8, 2018
9 Nutrition Screening Tool Today s Date: 1. What is your current weight? pounds (or kilograms) How tall are you? 2. Have you lost weight recently without trying? No (If NO, please go to question 3) Yes Unsure If YES, how much weight have you lost? 2-13 lbs (1) lbs (2) lbs (3) More than 33 lbs (4) Unsure (2) Over what time period have you lost this weight? Over the past two weeks Over the past month Over the past six months or more Are you still losing weight? No Yes Unsure 3. Have you been eating poorly because of a decreased appetite? _ No (0) Yes (1) If YES, how much are you eating now? about 75% of my usual amount about 50% of my usual amount about 25% of my usual amount 4. Are you having problems chewing food? _ No Yes 5. Are you having problems swallowing food? _ No Yes 6. Are you having 3 or more watery bowel movements per day? _ No Yes For Health Professional Use: Revised April /
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