IPOS Form

Q1. What have been the patient's main problems over the past 3 days? 0/100

Q2. Please tick the box that best describes how the patient has been affected by each of the following symptoms over the past 3 days? Pain Shortness of breath Weakness or lack of energy Nausea (feeling like you are going to be sick) Vomiting (being sick) Poor appetite Constipation Sore or dry mouth Drowsiness Poor mobility

Q3. Has s/he been feeling anxious or worried about his/her illness or treatment?

Q4. Have family/friends been anxious or worried about the patient?

Q5. Do you think s/he felt depressed?

Q6. Do you think s/he has felt at peace?

Q7. Shared feelings with family/friends as much as wanted?

Q8. Had as much information as wanted?

Q9. Practical problems addressed?

Q10. How was this completed? A: Patient completed on their own B: With help from friend/relative C: With help from staff