You can print page 8 only to use the 1–10 symptom rating scale. Write down your symptoms or concerns on the page (include as many as needed) and bring it with you to your healthcare provider.
- Patient and caregiver versions available
- English and Spanish versions available
- Save paper! This is a lengthy document, so please print only the pages you needed.
Recommended print settings: Select “Custom Pages” and enter the page range you need (e.g., 2–4, 5–7, or 8–8 to print page 8 only).
Includes:
Patient Rating Single sheet – Includes blank spaces for patients for written responses, and helpful prompts to circle to describe symptoms, needs, and concerns (open ended/write-in version).
Caregiver Rating Single sheet – Allows caregivers to rate and describe the patient’s symptoms, needs, and concerns, with blank spaces and helpful prompts to guide responses (open ended/write-in version).
Symptom & Concern Checklist – Provides suggestions and options to circle to help identify and describe symptoms, needs, and concerns (circle and choices version)