Fraser Health Hospice Palliative Care Program Symptom Assessment Acronym Symptom of concern Patient's primary concern in relation to the symptom Date: PPS Onset P Provoking/Palliating Quality RRegion/Radiation S Severity T Treatment UUnderstanding / Impact on You Physical assessment (as appropriate for symptom). VValues Physician When did It begin? How long does it last? How often does it occur? What brings it on? What makes it better? What makes it worse? What does it feel like! Can you describe it! Where Is it? Does It spread anywhere! What is the Intensity of this symptom (On a scale of 0 to 10 with O being none and 10 being worst possible)? Right now? At best? At worst? On average? How bothered are you by this symptom? Are there any other symptom(s) that accompany this symptom? What medications and treatments are you currently using? How effective are these? Do you have any side effects from the medications and treatments? What medications and treatments have you used in the past! What do you believe is causing this symptom? How is this symptom affecting you and / or your family? What is your goal for this symptom? What is your comfort goal or acceptable level for this symptom (On a scale of 0 to 10 with 0 being none and 10 being worst possible)? Are there any other views or feelings about this symptom that are important to you or your family? Signature: