Who do you rely on for emotional support


1. Home Environment: 

Lives with Spouse         

Lives Alone 

Lives with family 

Living with friend

2.  Who do you rely on for emotional support?   Family   Other

3.  How does your illness/hospitalization affect your family significant others?

4. Have you had any recent changes in your life (job, move, divorce, death, major surgeries, recent abuse, new illness)

5. Do you feel you are dealing successfully with stresses associated with this change?

6. What helps you sleep? Moms presence provides comfort and a sense of calmness

7. What concerns you most about your illness/ hospitalization?

8. Does your illness and/ or hospitalization affect your sexuality/ body image?  

9. Is religion important in your life? 

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