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Final Summary (Incl Karnofsky)
Patient
*
First Name
*
Surname
*
Patient Name
Date
*
Care Priority
High
Medium
Low
Visit Frequency
Bi-weekly
Weekly
Fortnightly
Monthly
On Call
Strong Opioids
Yes
No
Anti Depressants
Yes
No
Pain Score
0
1
2
3
4
5
6
7
8
9
10
Nausea Score
0
1
2
3
4
5
6
7
8
9
10
Dyspnoea Score
0
1
2
3
4
5
6
7
8
9
10
GHQ 12
0
1
2
3
4
5
6
7
8
9
10
Family Support
Supportive
Non-Supportive
Family Functional Status
Functional
Semi-Functional
Dysfunctional
Caregiver Attitude
Positive
Negative
Patient's Insight
Aware
Don't Want to Know
Denial
Want to Know
Collusion
Communication pattern
Withdrawn
Easy to talk
Slurred Speech
Unable to Talk
Karnofsky Performance Scale
0-100
Completed by PALCARE team member