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Contact Us
402-334-4773
Get To Know Us
Get To Know Us
What is Community Oncology
Choosing Your Provider
Physicians
Advanced Practice Providers
Nurse Case Managers
NCS Timeline
Patients
Patients
Your First Visit to NCS
New Patient Forms
Insurance and Financial Services
Locations
Services
Services
Medical Oncology
Radiation Oncology
Nuclear Oncology
Hematology
Imaging
Occupational Therapy
Nutrition Services
Mental Health
Pharmacy
Genetic Counseling
Clinical Research Trials
Dignicap®
Tumor Profiling
PSMA
Movement for Longevity
Supportive Care Clinic
Resources
Resources
Healthy U
Peer Mentor Program
NCS Focus Magazine
Education
Podcasts
NCS in the News
Support Organizations
NCS Hope Foundation
For Providers
Careers
SEARCH
Geriatric Assessment
Step
1
of
5
20%
First Name
*
Last Name
*
Birthdate
*
MM slash DD slash YYYY
Your Daily Activities
PATIENT INSTRUCTIONS: Indicate your response by selecting one box per question.
Can you use the telephone...
*
without help, including looking up and dialing;
with some help (can answer phone or dial operator in an emergency, but need a special phone or help in getting the number or dialing); or
are you completely unable to use the telephone?
Can you get to places out of walking distance...
*
without help (can travel alone on busses, taxis, or drive your own car);
with some help (need someone to help you or go with you when traveling); or
are you unable to travel unless emergency arrangements are made for a specialized vehicle like an ambulance?
Can you go shopping for groceries or clothes (assuming you have transportation)...
*
without help (taking care of all shopping needs yourself, assuming you have transportation);
With some help (need someone to go with you on all shopping trips); or
are you completely unable to do any shopping?
Can you prepare your own meals...
*
without help (plan and cook full meals yourself);
with some help (can prepare some things but unable to cook full meals yourself); or
are you completely unable to prepare any meals?
Can you do your housework...
*
without help (can clean floors, etc.);
with some help (can do light housework but need help with heavy work); or
are you completely unable to do any housework?
Can you take your own medicines...
*
without help (in the right doses at the right time);
with some help (able to take medicine if someone prepares it for you and/or reminds you to take it); or
are you completely unable to take your medicines?
Can you handle your own money...
*
without help (write checks, pay bills, etc.);
with some help (manage day-to-day buying but need help with managing your checkbook and paying your bills); or
are you completely unable to handle money?
Does your health limit you in these activities?
The following items are activities you might do during a typical day. Does your health limit you in these activities? (Mark an X in the box on each line that best reflects your situation.)
Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
*
Limited a lot
Limited a little
Not limited at all
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
*
Limited a lot
Limited a little
Not limited at all
Lifting or carrying groceries
*
Limited a lot
Limited a little
Not limited at all
Climbing several flights of stairs
*
Limited a lot
Limited a little
Not limited at all
Climbing one flight of stairs
*
Limited a lot
Limited a little
Not limited at all
Bending, kneeling, or stooping
*
Limited a lot
Limited a little
Not limited at all
Walking more than a mile
*
Limited a lot
Limited a little
Not limited at all
Walking several blocks
*
Limited a lot
Limited a little
Not limited at all
Walking one block
*
Limited a lot
Limited a little
Not limited at all
Bathing or dressing yourself
*
Limited a lot
Limited a little
Not limited at all
Current Health Rating
Which one of the following phrases best describes you at this time?
*
Please select one
Normal, no complaints, no symptoms of disease
Able to carry on normal activity, minor symptoms of disease
Normal activity with effort, some symptoms of disease
Care for self, unable to carry on normal activity or to do active work
Require occasional assistance but able to care for most of personal needs
Require considerable assistance for personal care
Disabled, require special care and assistance
Severly disabled, require continuous nursing care
Falls
How many times have you fallen in the last 6 months?
*
Medications
Are you taking any medications?
*
Yes
No
How many prescribed medications are you taking?
*
How many over-the-counter medications are you taking?
*
How many herbs and vitamins are you taking?
*
Your Health
Patient Instructions: Do you have any of the following illnesses at the present time, and if so, how much does it interfere with your activities: Not at All, A Little, or A Great Deal? (Select the box that best reflects your answer.)
Other cancers or leukemia
*
No
Yes
How much does it interfere with your activities?
*
Not at All
A Little
A Great Deal
Arthritis or rheumatism
*
No
Yes
How much does it interfere with your activities?
*
Not at All
A Little
A Great Deal
Glaucoma
*
No
Yes
How much does it interfere with your activities?
*
Not at All
A Little
A Great Deal
Emphysema or chronic bronchitis
*
No
Yes
How much does it interfere with your activities?
*
Not at All
A Little
A Great Deal
High blood pressure
*
No
Yes
How much does it interfere with your activities?
*
Not at All
A Little
A Great Deal
Heart trouble
*
No
Yes
How much does it interfere with your activities?
*
Not at All
A Little
A Great Deal
Circulation trouble in arms or legs
*
No
Yes
How much does it interfere with your activities?
*
Not at All
A Little
A Great Deal
Diabetes
*
No
Yes
How much does it interfere with your activities?
*
Not at All
A Little
A Great Deal
Stomach or intestinal disorders
*
No
Yes
How much does it interfere with your activities?
*
Not at All
A Little
A Great Deal
Osteoporosis
*
No
Yes
How much does it interfere with your activities?
*
Not at All
A Little
A Great Deal
Liver disease
*
No
Yes
How much does it interfere with your activities?
*
Not at All
A Little
A Great Deal
Kidney disease
*
No
Yes
How much does it interfere with your activities?
*
Not at All
A Little
A Great Deal
Stroke
*
No
Yes
How much does it interfere with your activities?
*
Not at All
A Little
A Great Deal
Depression
*
No
Yes
How much does it interfere with your activities?
*
Not at All
A Little
A Great Deal
How is your eyesight (with glasses or contacts)?
*
Excellent
Good
Fair
Poor
Totally blind
How much does it interfere with your activities?
*
Not at All
A Little
A Great Deal
How is your hearing (with a hearing aid, if needed)?
*
Excellent
Good
Fair
Poor
Totally deaf
How much does it interfere with your activities?
*
Not at All
A Little
A Great Deal
Do you have any other physical problems or illnesses (other than those listed above) at the present time that seriously affect your health?
*
No
Yes
If the above answer is yes, please specify the physical problem/illness:
How much does it interfere with your activities?
*
Not at All
A Little
A Great Deal
Nutritional Status
Have you lost weight involuntarily over the past 6 months?
*
No
Yes
If yes, how much?
Pounds or Kilograms?
Please select
Pounds
Kilograms
Health Questionnaire
INSTRUCTIONS: These questions are about how you have been feeling within the past month. Please mark an "X" in the box on each line that best reflects your situation.
How much of the time during the past month:
has your daily life been full of things that were interesting to you?
*
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
did you feel depressed?
*
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
have you felt loved and wanted?
*
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
have you been in firm control of your behavior, thoughts, emotions, feelings?
*
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
have you felt tense or high-strung?
*
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
have you felt calm or peaceful?
*
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
have you felt emotionally stable?
*
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
have you felt restless, fidgety, or impatient?
*
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
have you felt downhearted and blue?
*
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
have you been moody, or brooded about things?
*
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
have you felt cheerful, light-hearted?
*
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
have you been in low or very low spirits?
*
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
were you a happy person?
*
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
did you feel you had nothing to look forward to?
*
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
have you felt so down in the dumps that nothing could cheer you up?
*
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
have you been anxious or worried?
*
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
have you been a very nervous person?
*
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
Social Activities
During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?
*
All of the Time
Most of the Time
A Good Bit of the Time
Some of the Time
A Little of the Time
None of the Time
Compared to your usual level of social activity, has your social activity during the past 6 months decreased, stayed the same, or increased because of a change in your physical or emotional condition?
*
Much less socially active than before
Somewhat less socially active than before
About as socially active as before
Somewhat more socially than before
Much more socially active than before
Compared to others your age, are your social activities more or less limited because of your physical health or emotional problems?
*
Much more limited than others
Somewhat more limited than others
About the same as others
Somewhat less limited than others
Much less limited than others
Social Support
INSTRUCTIONS: People sometimes look to others for companionship, assistance or other types of support. How often is each of the following kinds of support available to you if you need it? (Mark an X in the box on each line that best reflects your situation.)
Someone to help if you were confined to bed.
*
None of the Time
A Little of the Time
Some of the Time
Most of the Time
All of the Time
Someone you can count on to listen to you when you need to talk.
*
None of the Time
A Little of the Time
Some of the Time
Most of the Time
All of the Time
Someone to take you to the doctor if you needed it.
*
None of the Time
A Little of the Time
Some of the Time
Most of the Time
All of the Time
Someone to give you information to help you understand a situation.
*
None of the Time
A Little of the Time
Some of the Time
Most of the Time
All of the Time
Someone to confide in or talk to about yourself or your problem.
*
None of the Time
A Little of the Time
Some of the Time
Most of the Time
All of the Time
Someone to prepare your meals if you were unable to do it yourself.
*
None of the Time
A Little of the Time
Some of the Time
Most of the Time
All of the Time
Someone whose advice you really want.
*
None of the Time
A Little of the Time
Some of the Time
Most of the Time
All of the Time
Someone to give you good advice about a crisis.
*
None of the Time
A Little of the Time
Some of the Time
Most of the Time
All of the Time
Someone to help you with daily chores if you were sick.
*
None of the Time
A Little of the Time
Some of the Time
Most of the Time
All of the Time
Someone to share your most private worries and fears with.
*
None of the Time
A Little of the Time
Some of the Time
Most of the Time
All of the Time
Someone to turn to for suggestions about how to deal with a personal problem.
*
None of the Time
A Little of the Time
Some of the Time
Most of the Time
All of the Time
Someone who understands your problems.
*
None of the Time
A Little of the Time
Some of the Time
Most of the Time
All of the Time
Spirituality/Religion
Please answer the following questions about your religious beliefs and/or involvement. Select the answer that best reflects your situation.
How often do you attend church, synagogue, or other religious meetings?
*
More than once per week
Once a week
A few times a month
A few times a year
Once a year or less
Never
How often do you spend time in private religious activities, such as prayer, meditation or Bible study?
*
More than once a day
Daily
Two or more times per week
Once a week
A few times a month
Rarely or never
The following section contains 3 statements about your religious belief or experience. Please select the extent to which each statement is true or not true for you.
In my life, I experience the presence of the Divine (i.e., God).
*
Definitely true of me
Tends to be true
Unsure
Tends not to be true
Definitely not true
My religious beliefs are what really lie behind my whole approach to life.
*
Definitely true of me
Tends to be true
Unsure
Tends not to be true
Definitely not true
I tried hard to carry my religion over into all other dealings in my life.
*
Definitely true of me
Tends to be true
Unsure
Tends not to be true
Definitely not true
Your Feelings
Do you often feel sad or depressed?
*
No
Yes
How would you describe you level of anxiety, on the average? Please select the number (0-10) best reflecting your response to the following that describes your feelings during the past week, including today.
*
0 (No Anxiety)
1
2
3
4
5
6
7
8
9
10 (Anxiety as bad as it can be)
Data Collection
Information gained from this questionnaire may be used for future clinical research and/or data collection by Nebraska Cancer Specialists. NO patient identifiers will be associated with the data retrieved.
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