Add Screening Questions

[dman7]

Screening questions:

1. In terms of anxiety, select the number that best describes how you feel now

(anxiety=feeling nervous).

a. Response options: 0 (No anxiety) – 10 (worst possible anxiety)

2. In terms of pain, select the number that best describes how you feel now.

a. Response options: 0 (No pain) – 10 (worst possible pain)

3. In terms of tiredness, select the number that best describes how you feel now

(tiredness=lack of energy).

a. Response options: 0 (No tiredness) – 10 (worst possible tiredness)

4. In terms of drowsiness, select the number that best describes how you feel

now (drowsiness=feeling sleepy).

a. Response options: 0 (No drowsiness) – 10 (worst possible

drowsiness)

5. In terms of nausea, select the number that best describes how you feel now

a. Response options: 0 (No nausea) – 10 (worst possible nausea)

6. In terms of lack of appetite, select the number that best describes how you

feel now.

a. Response options: 0 (no lack of appetite) – 10 (worst possible lack of

appetite)

7. In terms of shortness of breath, select the number that best describes how

you feel now.

a. Response options: 0 (No shortness of breath) – 10 (worst possible

shortness of breath)

8. In terms of depression, select the number that best describes how you feel

now

a. Response options: 0 (No depression) – 10 (worst possible depression)

9. In terms of wellbeing, select the number that best describes how you feel

now

a. Response options: 0 (Best wellbeing) – 10 (worst possible wellbeing)

10. In the last two weeks, have you had any bruising or bleeding?

a. Response options: YES, NO

11. When was the last time you had a bowel movement?

a. Response options: TODAY, YESTERDAY, TWO OR MORE DAYS AGO

12. Follow- up question  Is this your normal pattern?

a. Response options: YES/NO

13. Follow-up question Is your stool loose?

a. Response options: YES/NO

14. In the last two weeks, have you had a fever?

a. Response options: YES, NO

15. In the last two weeks, has your mouth been sore or sensitive?

a. Response options: YES, NO

16. In the last two weeks, have you vomited?

a. Response options: YES, NO

17. In the last two weeks, have you felt pins and needles or tingling and numbness in your fingers or toes?

a. Response options: YES, NO

18. In the last two weeks, have you had any changes in your skin?

a. Response options: YES, NO

19. Follow-up question  In the last two weeks, has your skin felt dry, itchy or changed in color?

a. Response options: YES, NO

[dman7]

Closed via #591