DISTRESS-BAROMETER
Confidential (for medical file )
A. How much distress have you been
experiencing in the past week ?
Please put a cross on the thermometer.
Name patient:
Date:
Please fill in all three sections A and B and C!
B. This table lists some of the problems you might be experiencing these days. Please
indicate with a cross to what extent these problems are bothering you.
Not at all
A little
Some
A lot
Pain
10
9
Extreem
EExtreme
xtreem lastig
distress
Other physical problems
8
Nervousness
7
Losing memory and/or
concentration
Fears
6
5
Worries about partner/family
4
3
Sadness
2
Anger
1
0
distress
HNo
elemaal
niet lastig
Spiritual concerns
Other problems
©Sabien Bauwens, Catherine Baillon, 2006,
Sabien.Bauwens@uzbrussel.be
C. I want to talk about these problems: □ no □ yes
If yes, with whom □ doctor □ nurse □ psychologist □ social nurse □ other person: …
Lately I have been in need of: □ more medical information □ better support
Very much