Do I need professional Help?
The following questionnaire may help you figure out whether professional counseling might be helpful to you. Every patient has some of these symptoms. Circle the answer that fits best for you, from 1 (not at all) to 5 (all the time) or one of the numbers in between. There are no right or wrong answers. Answer the questions honestly. If you try to cover up how you feel, you might not get the help you need.
During the past 2 weeks:
I have felt anxious or worried about cancer and the treatment I am receiving.
Not at all 1 2 3 4 5 All the time
I have felt depressed or discouraged
Not at all 1 2 3 4 5 All the time
I have been irritable or unusually angry and I have not controlled it well.
Not at all 1 2 3 4 5 All the time
My sleeping habits have changed.
Not at all 1 2 3 4 5 All the time
I have noticed a change in my appetite
Not at all 1 2 3 4 5 All the time
I have been having trouble focusing at work or at home or on routine things such as reading the newspaper or watching television.
Not at all 1 2 3 4 5 All the time
Cancer and its treatment have interfered with my daily activities
Not at all 1 2 3 4 5 All the time
Cancer and its treatment have interfered with my family or social life
Not at all 1 2 3 4 5 All the time
Cancer and its treatment have interfered with my sex life
Not at all 1 2 3 4 5 All the time
Cancer has caused physical, emotional or financial hardship for me
Not at all 1 2 3 4 5 All the time
Cancer and its treatment have caused changes in how I look, and this concerns me.
Not at all 1 2 3 4 5 All the time
I have been having trouble coping with the stress I am having
Not at all 1 2 3 4 5 All the time
The quality of my life during the past 2 weeks has been:
Excellent 1 2 3 4 5 Very Poor
If you find that many of your answers are 4s or 5s, you may be having serious distress and should think about talking with a mental health professional.
Source: Developed by the Department of Psychosocial resources, Tom Baker Cancer Center, Calgary, Alberta, Canada. Derived in part from the Functional Living Index : Cancer and from the EORTC Core Quality of Life Questionnaire.
