HOW OFTEN?

HOW DIFFICULT?

EVENT

1 = Never

2 = Rarely 3 = Sometines 4 = Often 5 = Very often

1 = Not at all

2 = A little 3 = Somewhat 4 = Very much 5 = Extremely

1. Difficulty Sleeping

1

2

3

4

5

1

2

3

4

5

2. Bringing my child to the clinic or hospital

1

2

3

4

5

1

2

3

4

5

3. Being unable to go work/job

1

2

3

4

5

1

2

3

4

5

4. Waiting for my childs test results

1

2

3

4

5

1

2

3

4

5

5. Trying not to think about my family’s difficulties

1

2

3

4

5

1

2

3

4

5

6. Trying to attend to the needs of other family members

1

2

3

4

5

1

2

3

4

5

7. Seeing my child sad or scared

1

2

3

4

5

1

2

3

4

5

8. Talking with the nurse

1

2

3

4

5

1

2

3

4

5

9. Making décisions about medical care or medicines

1

2

3

4

5

1

2

3

4

5

10. Having little time to take care of my own needs

1

2

3

4

5

1

2

3

4

5

11. Thinking about other children who have been seriously ill

1

2

3

4

5

1

2

3

4

5

12. Speaking with my child about his/ her illness

1

2

3

4

5

1

2

3

4

5

13. Speaking with family members about my child’s illness

1

2

3

4

5

1

2

3

4

5