IPOS Assessment (Staff Entry)

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1. Identify Patient

Zero Server-Side Retention: Form syncs directly to your Google Form. No patient identifiers are stored by the server.

2. Fill IPOS Data

Leave blank if cannot assess (e.g. unconscious)

Q1. What have been the patient's main problems over the past 3 days? 0/100

Q2. Please tick the box that best describes how the patient has been affected by each of the following symptoms over the past 3 days? PainShortness of breathWeakness or lack of energyNausea (feeling like you are going to be sick)Vomiting (being sick)Poor appetiteConstipationSore or dry mouthDrowsinessPoor mobility

Other symptoms

Emotional Distress (0 = Not at all ➝ 4 = Always)

Over the past 3 days:

Q3. Has s/he been feeling anxious or worried about his/her illness or treatment?

Q4. Have family/friends been anxious or worried about the patient?

Q5. Do you think s/he felt depressed?

Scale Reversed (0 = Always ➝ 4 = Not at all)

Over the past 3 days:

Q6. Do you think s/he has felt at peace?

Q7. Shared feelings with family/friends as much as wanted?

Q8. Had as much information as wanted?

Practical Resolution

Q9. Practical problems addressed?

Q10. How was this completed?

Total IPOS Score

Higher = More Distress

3. Clinical Context

IPOS Form

Identify Patient