Patient Distress Assessment Form
Please complete this assessment to help us understand your current distress level and support needs. This is not a diagnostic or medical form.
How would you rate your current level of distress?
*
No distress
0
1
2
3
4
5
6
7
8
9
Extreme distress
10
0 is No distress, 10 is Extreme distress
Which of the following are contributing to your distress? (Select all that apply)
Work or school pressures
Relationship or family issues
Health concerns
Financial worries
Loss or grief
Other
How urgent is your need for support?
*
Immediate (crisis or emergency)
Within 24 hours
In the next few days
Not urgent
What support would you prefer at this time?
*
Talk to a support person
Receive written resources
Schedule a follow-up
No support needed right now
Other
Which of these feelings have you experienced recently? (Select all that apply)
Anxiety or worry
Sadness or hopelessness
Anger or frustration
Fear or panic
Difficulty concentrating
Other
Please indicate how much each area of life is currently affected by distress.
Rows
Not at all
Somewhat
Very much
Work or school
1
2
3
Home life
4
5
6
Social life
7
8
9
Physical health
10
11
12
Sleep
13
14
15
Have you experienced distress like this before?
Yes, frequently
Yes, occasionally
No, this is new
Is there anything else you would like to share about your current distress or support needs?
Submit Assessment
Should be Empty: