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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