Chemotherapy Patient Outcome Survey
Please complete this survey to help us understand your experience with chemotherapy treatment and its outcomes.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Date of Last Chemotherapy Session
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Cancer Treated
*
Please Select
Breast cancer
Lung cancer
Colorectal cancer
Prostate cancer
Lymphoma
Leukemia
Other
Please indicate the severity of the following side effects experienced during your chemotherapy treatment:
*
Rows
None
Mild
Moderate
Severe
Nausea/Vomiting
1
2
3
4
Fatigue
5
6
7
8
Hair loss
9
10
11
12
Appetite loss
13
14
15
16
Pain
17
18
19
20
Neuropathy (numbness/tingling)
21
22
23
24
Mouth sores
25
26
27
28
How would you rate your overall quality of life during chemotherapy?
*
Very Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very Poor, 10 is Excellent
Since starting chemotherapy, how would you describe your physical well-being?
*
Much worse
Somewhat worse
No change
Somewhat better
Much better
How satisfied are you with the care and support you received during chemotherapy?
*
1
2
3
4
5
Please share any additional comments, concerns, or suggestions regarding your chemotherapy experience.
Submit Survey
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