Date: / / Study Name: (month) (day) (year) Protocol ...

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Capital Health Guidelines for using the Edmonton Symptom Assessment System (ESAS) CH-0373 Mar 2001 Regional Palliative Care Program Purpose of the ESAS This tool is designed to assist in the assessment of …

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The Brief Pain Inventory - NPCRC

25) I take my pain medicine (in a 24 hour period): 1. Not every day 4. 5 to 6 times per day 2. 1 to 2 times per day 5. More than 6 times per day

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Brief Fatigue Inventory - NPCRC

Date: / / Time:_____ Name:_____ _____ _____ Last First Middle Initial Brief Fatigue Inventory

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HAMILTON DEPRESSION RATING SCALE - NPCRC

The total Hamilton Depression (HAM-D) Rating Scale provides and indication of depression and, over time, provides a valuable guide to progress. • Classification of symptoms which may be difficult to obtain can be scored as:

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Caregiver Strain Index (CSI) - NPCRC

Caregiver Strain Index (CSI) I am going to read a list of things that other people have found to be difficult. Would you tell me whether any of these apply to you?

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McGILL QUALITY OF LIFE QUESTIONNAIRE - NPCRC

McGILL QUALITY OF LIFE QUESTIONNAIRE STUDY IDENTIFICATION #: DATE: Instructions The questions in this questionnaire begin with a statement followed by two opposite answers. Numbers extend from one extreme answer to its opposite. Please circle the number between 0 and 10 which is most true for you. There are no right or wrong answers.

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Geriatric Depression Scale (GDS) Short Form - NPCRC

Scoring for Geriatric Depression Scale • Score 1 point for every “yes” in questions 2, 3, 4, 6, 8, 9, 10, 12, 14, 15 • Score 1 point for every “no” in ...

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Parent-Teacher Involvement Questionnaire: Parent Version ...

1 Parent-Teacher Involvement Questionnaire: Parent Version Kindergarten /Year 1 Fast Track Project Technical Report Anne Corrigan September 26, 2002

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2018 LIHEAP APPLICATION INSTRUCTIONS

2018 LIHEAP APPLICATION INSTRUCTIONS LIHEAP provides one payment per program year for Electricity, Gas, Propane, Wood, or Oil to eligible households .. Please complete the attached application and provide the following documents:

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Which Vaccines Do I Need Today?

Which Vaccines Do I Need Today? Vaccines are an important part of helping you stay healthy. Which of these recommended vaccines do . you need? Check the boxes that apply to you, and then talk this over with your healthcare provider.

THE ‘SCHOOL AND PROGRAM’ QUESTIONNAIRE

1 Annex The ‘School and Program’ Questionnaire was divided into three parts: • Part I: Background questions about the school • Part II: Questions about Upper Secondary Schools (Human Resources, Aspects of Functioning,

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Questionnaire created for Studies on Women’s Empowerment ...

Questionnaire created for Studies on Women’s Empowerment, Position and Quality of Life in Poland and Eastern European, extended to

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