Sometimes it can be difficult to remember to talk about all the things that are bothering you at your clinic appointment.
This list will help remind you to discuss any problems you may need help with.
Please go through the list and select yes or no to any of the boxes that apply to you.
To help your care team understand how you are feeling in general, please select a number from 1 to 10 to show how you are feeling today.
8-10 means means you are feeling good and coping very well. 1-3 means things are not going well.
You can select whatever number you like. Choose the number that best shows how you are feeling today.