Download Checklist for Reporting Symptoms and Side Effects

PATIENT EDUCATION
patienteducation.osumc.edu
Checklist for Reporting Symptoms and
Side Effects
Reporting Side Effect
It is common to have some side effects or problems related to treatment
for cancer or blood diseases. These side effects are also called
symptoms. Many symptoms can be controlled or managed. The first
step is keeping track of problems and then talking about them with your
health care team.
Symptom Checklist
This reporting sheet has a list of symptoms or side effects that could
happen. A person will not have all of these problems. If you do have
one of these side effects, please record it on this sheet. Or if you have a
problem that is not listed, you can write it in the space for “other”.
How to use this Symptom Checklist
On the day that you have one or more of these side effects write the
date at the top of the column. Place a mark (x) in the column next to
the symptom that you have. Record a mark every time you have the
problem.
Write how severe or bad the side effect was in the comment section.
You may use a “0 to 10” scale that is described below. Also write what
made the side effect better or worse. If you called your nurse or doctor,
you may also write down that information.
Tip: Bring this checklist with you when you come for your
treatment to help you discuss the side effects with your
nurse or doctor. You may photocopy these pages.
This handout is for informational purposes only. Talk with your doctor or health care
team if you have any questions about your care.
© April 13, 2017. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard
J. Solove Research Institute.
Pain Scales
A pain rating scale is a tool you can use to help explain how much pain
you feel and to set goals for pain relief.
Defense and Veterans Pain Rating Scale (DVPRS)
Choose the face that shows how much pain you feel or use the number
under that face to rate your pain.
Defense and Veterans Pain Rating Scale
SEVERE
(Red)
MODERATE
(Yellow)
MILD
(Green)
No pain
Hardly
notice
pain
Notice pain,
does not
interfere
with
activities
Sometimes
distracts
me
Distracts
me, can
do usual
activities
Interrupts
some
activities
Hard to
Focus of
ignore,
attention,
avoid usual prevents
activities
doing daily
activities
Awful,
hard to do
anything
Can’t bear
the pain,
unable to
do anything
As bad as
it could be,
nothing
else
matters
v 2.0
0 to 10 Rating Scale for Symptoms
A “0 to 10” scale is helpful to rate a side effect, symptom, or problem.
You can use a scale like this one below for any symptom. On this scale
zero (0) means the problem is gone; a “2” would mean the problem is
mild; a “9” would mean the problem is very severe. A “10” would mean
the problem was the worst possible.
Checklist for Reporting Symptoms and Side Effects
Symptom Checklist for Tracking: Symptoms & Side Effects of Cancer
Treatment
Date →
General Side Effects:
Headache
Dizzy
Fainting
Weakness
Nose bleeds
Unusual bleeding
Bruising
Fatigue
Pain
Chills
Other
Stomach / Bowel:
Weight loss
Checklist for Reporting Symptoms and Side Effects
Comments
Date →
Weight gain
Nausea
Vomiting
Taste changes
Mouth sores
Decreased appetite
Stomach cramps
Diarrhea
Constipation
Other
Bladder / Urination:
Painful urination
Leaking urine
Frequency of
urination
Burning while
urinating
Checklist for Reporting Symptoms and Side Effects
Comments
Date →
Foul smelling urine
Blood in urine
(pink / red)
Other
Sexuality:
Painful intercourse
Vaginal bleeding
Change in desire
Vaginal dryness
Erectile dysfunction
Other
Infection:
Fever
Chills
Drainage
Checklist for Reporting Symptoms and Side Effects
Comments
Date →
Swollen glands
Pain at catheter / IV
site
Pain or red wound
site
Other
Skin:
Hair loss
Change in skin color
Skin dryness
Rash
Itching
Other
Nervous System:
Ringing in ears
Numbness in fingers
or toes
Checklist for Reporting Symptoms and Side Effects
Comments
Date →
Vision changes
Leg cramps
Loss of hearing
Balance problems
Other
Heart and Lung:
Swelling or
temperature changes
arms or legs
Heart flutters
Chest pain
Bloating
Wheezing
Cough
Shortness of breath
Pain in arms / legs
Other
Checklist for Reporting Symptoms and Side Effects
Comments
Date →
Thinking & Feeling:
“Jitters” nervous
Difficulty sleeping
Loss of concentration
Loss of memory
Confusion
Depression
Agitation /
restlessness
Sleeping a lot
Other
Other Symptoms (List):
Checklist for Reporting Symptoms and Side Effects
Comments
Date →
Comments
Other Symptoms (List):
More Information
Here is a list of patient education handouts that are available to help you
learn more about symptoms:
•
Pain Management
•
Cancer Therapy: Managing Side Effects - Fatigue
•
Fight Cancer-Related Fatigue with Good Nutrition
•
Using Exercise to Fight Cancer-Related Fatigue
•
Taking Your Temperature
•
Cancer Therapy: Managing Side Effects - Taste Changes
•
Cancer Therapy: Managing Side Effects - Nausea and Vomiting
•
Peripheral Neuropathy Caused by Cancer Treatment
•
Cancer Therapy: Managing Side Effects - Mouth Sores
•
Eating Tips for Managing Cancer Treatment Side Effects
•
What You Can Do to Sleep Better
•
Preventing Bleeding When You Have a Low Platelet Count
•
Emergency Care for Patients of The James
Checklist for Reporting Symptoms and Side Effects