Date: / / Patient s Project ID# For use as-needed in clinic visits A SURVEY TO LEARN ABOUT A PATIENT S NEEDS AND ABILITIES: Health care providers of children and adolescents aged 5 to 2 How is this patient doing today? [Mark the box below the face best describing how you think this patient feels] Is this patient doing better, the same, or worse than a week ago? [Circle one number] Much Better Better Same Worse Much Worse Does any part of this patient s body hurt? No Yes THIS PATIENT HURTS HERE THE MOST: IT HURTS THIS PATIENT THIS MUCH [Circle one number] No Hurt Hurt Most Hurt AND IT BOTHERS THIS PATIENT THIS MUCH [Circle one number] Never Always Page 1
4. other children and teenagers have these symptoms when they are sick. Please circle any of these symptoms this patient has had in the last week. Trouble breathing Coughing Itchy skin Skin sores Feeling weak Feeling tired Trouble sleeping Head hurts Sick to his/her stomach Stomach pain Throwing up Trouble seeing Not hungry Dry mouth Hair falling out Trouble hearing Trouble with bowel Loose bowel Wetting the bed Urinating in his or her clothes movements movements Constipation Diarrhea Mouth sores Stuffy Nose Swelling Hiccups Drooling Other symptoms: (list) 5. In the box below, please list up to 3 symptoms that have bothered this patient the most this past week: No symptoms have bothered this patient. SYMPTOMS THAT HAVE BOTHERED THIS PATIENT THE MOST THIS PAST WEEK: THIS SYMPTOM BOTHERS THIS PATIENT THIS MUCH [circle one number for each symptom] a little a lot 6. How tired has this patient been during the day, this past week? Please circle one of the numbers in the box below. Tired a little Tired a lot Page 2
7. What things were used to make this patient s symptoms better? List up to 3 things in the box below. THINGS USED TO MAKE THIS PATIENT S SYMPTOMS BETTER Helped a little HOW WELL THEY WORKED [circle one number for each thing] Helped a lot 8. Overall, how satisfied are you with the things that were used to relieve this patient s symptoms? DID IT WORK? Relief of this Patient s Symptoms LEVEL OF SATISFACTION [circle one number for each question] Not Satisfied Somewhat Satisfied Very Satisfied Page 3
9. other children and teenagers have problems doing these things listed in the box below. Please circle any of these things that are harder for this patient to do now than they used to be. Thinking Learning Remembering Doing schoolwork Talking Reading Doing math 10. What problems with thinking or learning bother this patient the most? [List up to 3 in the box below.] This patient has no problems with thinking or learning. PROBLEMS WITH THINKING OR LEARNING THAT BOTHER THIS PATIENT: THIS PROBLEM BOTHERS THIS PATIENT THIS MUCH [circle one number for each problem] a Little a Lot 1 What thinking or learning is this patient doing that makes him/her feel happy or proud? [List up to 3 in the box below.] THINKING OR LEARNING THAT MAKES THIS PATIENT FEEL HAPPY OR PROUD: THIS ABILITY PLEASES THIS PATIENT THIS MUCH [circle one number for each ability] a Little a Lot Page 4
1 other children and teenagers have trouble doing these activities listed in the box below. Please circle any of these activities that are harder for this patient to do now than they used to be. Moving around Walking Playing Drinking Hearing Seeing Eating Going out Taking a bath Watching TV Going to school Other activities: (list) Getting to the bathroom Playing sports 1 What activities give this patient the most problems? [List up to 3 activities in the box below] This patient has no problems doing activities. ACTIVITIES THAT GIVE THIS PATIENT THE MOST PROBLEMS: THIS ACTIVITY BOTHERS THIS PATIENT THIS MUCH [circle one number for each activity] a little a lot 14. What activities make this patient the happiest or proudest? [List up to 3 activities in the box below] THESE ACTIVITIES MAKE THIS PATIENT THE HAPPIEST OR PROUDEST: THIS ACTIVITY PLEASES THIS PATIENT THIS MUCH [circle one number for each activity] a Little a Lot Page 5
15. other children or teenagers feel that they don t always do the things they d like to do or are treated the way they d like to be treated. Please circle one number for each question, reflecting how you think this patient feels. HOW OFTEN? Never Half the Time Most Times Always Does this patient do enough of the things he or she wants to do? Does this patient spend enough time with the people he or she wants to? Does this patient talk enough about things he or she wants to talk about? 4. How much are people listening to this patient? 5. Does this patient feel supported by people who matter to him or her? 6. Does this patient do things that other kids or teenagers his or her age do? 7. Does this patient have to follow the rules of the house? 16. other children or teenagers feel worried about their family and friends. Please circle one number for each question below, showing how worried you think this patient is. Not at all Worried Somewhat Worried Very Worried How worried is this patient about his or her family? How worried is this patient about his or her friends? Page 6
17. How often does this patient do or feel the things listed in the box below? Please circle one number for each question. HOW OFTEN DOES THIS PATIENT? Never Always Choose what he or she does? Decide what medical things happen to him or her? Control what happens to him or her? 4. Get the privacy he or she wants? 5. Feel confused about what is happening to him or her? 18. How often does this patient feel the emotions listed in the box below? Please circle one number for each question. HOW OFTEN DOES THIS PATIENT FEEL? Never Always Happy? Sad? Peaceful? 4. Worried? 5. Safe? 6. Scared? 7. Nervous? 8. Loved? 9. Lonely? 10. Angry? 1 Happy about himself or herself? 1 Happy about how he or she looks? Page 7
19. Does this patient have things he or she hopes for? No Yes [List up to 3 things in the box below] THINGS MY PATIENT HOPES FOR MY PATIENT HOPES FOR THIS THING THIS MUCH [circle one number for each thing] Just a Little Pretty Much More than Anything Else 20. Are there reasons that this patient believes about why he or she is ill? No Yes [List up to 3 reasons in the box below] MY PATIENT BELIEVES THESE ARE THE REASONS WHY HE OR SHE IS ILL No Sense THIS REASON MAKES SENSE TO MY PATIENT THIS MUCH [circle one number for each reason] Some Sense Perfect Sense 2 Is there anything else you want to tell us? Page 8