By National Family Caregivers Association

Print this guide to help you better understand your loved one's pain and well-being. By regularly monitoring your loved one's symptoms, complaints, and progress, you can help your healthcare professional help your loved one.

Pain

Is your loved one complaining about pain? What does he/she say it feels like? (Circle the appropiate description)

• Sharp
• Stabbing
• Dull
• Pounding
• Achy
• Tingling
• Other

Where is the pain located? (Circle the appropiate description)

• All Over
• Headache
• Abdomen
• Limbs
• Other location

Other Questions about Pain

1. On a scale of 1-10, with 1 being no pain and 10 being the worst pain imaginable, how does your loved one rate his pain?
2. How long has the pain lasted?
3. Does the pain move around or stay in one place?
4. Does the pain come and go, or is it there all the time?
5. Does the pain seem to occur in relation to something else (e.g., eating, standing up suddenly, while reaching for something overhead)?
6. Is there anything that makes the pain better or worse?
7. Does pain medication help? If so, how much?

Medications

1. Is your loved one taking his medications on time? At the prescribed dose? If not, what seems to be going wrong?
2. Is he/she complaining about or suffering from any side effects? If so, what are they (drowsiness, hyperactivity, etc.)?
3. Does anything seem to have suddenly changed in his response to medication? If so, what is it?
4. Did he stop taking a medication for any reason? If so, why and what happened as a result?

Overall Well-Being

1. Is your loved one eating well? Any sudden changes in diet or fussiness about eating?
2. Any sudden cravings?
3. Is his weight stable? If not, what is happening?
4. Is he sleeping well? Unable to fall asleep? Waking up and unable to go back to sleep?
5. Does he have nightmares? Sleep restlessly?
6. Is he getting some kind of exercise? Suddenly doing more or less than typical?
7. Is there any sign of abuse or neglect that you’ve noticed? If so, what is it?

General Condition

1. Does your loved one seem to have “slowed down” noticeably since the last doctor visit? If so, in what way?
2. Does he have any unusual bleeding? Where? How much?
3. Does he seem to be breathing easily? If not, what is the quality of the breathing, ie., rapid, shallow, gasping, rattling, other?
4. Does he cough when he eats or drinks?
5. Is his digestive system working well? If not, what seems to be the matter
   (excessive gas, heartburn, diarrhea, constipation, other)?
6. Are his limbs moving as they usually do? Is he struggling to handle things?
7. Have any rashes or welts appeared recently? Where? What do they look like?
8. Has a mole changed shape or become dark? Has a new one appeared somewhere? If so, where?
9. In general, does the treatment plan seem to be working? If not, what seems to be wrong?
10. Is a particular problem the reason for this office visit? If so, what are the major symptoms or concerns?

Emotional & Mental Well-Being

1. Does your loved one seem to be as mentally sharp and alert, or has there been a noticeable decrease in mental function? What are the symptoms?
2. How is his memory, both long-term and short-term? Has it changed recently? If so, in what way?
3. Can he still do and enjoy activities as in the past? Has something suddenly become boring or unpleasant?
4. Does he feel responsible for being ill and/or angry about his condition?
5. Does he fear the truth and put off doctor visits based on what he thinks the doctor may say about his problem?
6. Is he able to laugh and enjoy life?
7. Does he seem to be more emotionally overwrought than usual? In what way(anxious, depressed, fearful, sad, hyped-up, excitable, other)?

Spiritual Well-Being

1. Are there any restrictions on treatment that need to be considered due to the patient’s spiritual beliefs or practices? If so, what are they?
2. Has the patient continued his usual spiritual practices (e.g., going to church, meditation, saying the rosary, prayer, using a home altar)? If not, what has changed?
3. Has he started expressing doubts about faith or spiritual practices?
4. Does he seem more reflective and quiet than usual? If so, does this seem to be okay?
5. Is he starting to talk about wanting to “go home” in the sense of dying?

Other Conditions

Each illness has its own set of unique symptoms. Ask your doctor if there are particular symptoms that should be monitored.

Originally published by the National Family Caregivers Association (NFCA). Reprinted with permission.

National Family Caregivers Association (NFCA) educates, supports, and speaks up for the more than 65 million Americans who care for loved ones with a chronic illness, disability or frailty. NFCA reaches across the boundaries of diagnoses, relationships and life stages to address the common needs and concerns of all family caregivers. For more information visit www.thefamilycaregiver.org.