1. ‫ﻧﻤﻮذج ﻓﺤﺺ أﻋﺮاض اﻟﺮﻋﺎﻳﺔ اﻟﺘﻠﻄﻴﻔﻴﺔ‬
‫_________________ :‪Patient Dx‬‬ ‫اﻟﺘﺸﺨﻴﺺ:‬ ‫اﻟﺘﺎرﻳﺦ:_____________ :‪Date‬‬
‫اﻟﺮﻗﻢ:______________:#‪ID‬‬ ‫اﻟﻤﺮآﺰ:_____________ :‪Center Name‬‬
‫أﺳﻮأ أﻟﻢ ﻣﻤﻜﻦ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫ﻻ ﻳﻮﺟﺪ أﻟﻢ‬
‫أﺳﻮأ إﻋﻴﺎء ﻣﻤﻜﻦ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫ﻻ ﻳﻮﺟﺪ إﻋﻴﺎء‬
‫أﺳﻮأ ﻏﺜﻴﺎن ﻣﻤﻜﻦ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫ﻻ ﻳﻮﺟﺪ ﻏﺜﻴﺎن‬
‫أﺳﻮأ إﺣﺒﺎط ﻣﻤﻜﻦ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫ﻻ ﻳﻮﺟﺪ إﺣﺒﺎط‬
‫أﺳﻮأ ﺗﻮﺗﺮ ﻣﻤﻜﻦ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫ﻻ ﻳﻮﺟﺪ ﺗﻮﺗﺮ‬
‫أﺳﻮأ دوﺧﺔ ﻣﻤﻜﻨﺔ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫ﻻ ﻳﻮﺟﺪ دوﺧﺔ‬
‫أﺳﻮأ ﺿﻴﻖ ﻧﻔﺲ ﻣﻤﻜﻦ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫ﻻ ﻳﻮﺟﺪ ﺿﻴﻖ ﻧﻔﺲ‬
‫أﺳﻮأ ﺷﻬﻴﺔ ﻣﻤﻜﻨﺔ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫أﻓﻀﻞ ﺷﻬﻴﺔ ﻣﻤﻜﻨﺔ‬
‫أﺳﻮأ ﻧﻮم ﻣﻤﻜﻦ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬ ‫أﻓﻀﻞ ﻧﻮم ﻣﻤﻜﻦ‬
‫أﻓﻀﻞ ﺷﻌﻮر‬
‫أﺳﻮأ ﺷﻌﻮر ﻣﻤﻜﻦ‬ ‫01‬ ‫9‬ ‫8‬ ‫7‬ ‫6‬ ‫5‬ ‫4‬ ‫3‬ ‫2‬ ‫1‬ ‫0‬
‫ﻣﻤﻜﻦ‬
‫اﻟﻔﺎﺣﺺ:___________________ :‪Assessed by‬‬
‫.‪Source: The University of Texas, MD Anderson Cancer Center‬‬
‫00279 ‪733 Dr. Geminer St., Karkafa, Bethlehem –Palestine. P.O. Box: 19960 East Jerusalem‬‬
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