Chemotherapy Anemia Assessment Form
Please complete this form to help evaluate anemia symptoms and related factors in patients undergoing chemotherapy.
Patient Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
Date
Current Hemoglobin Level (g/dL)
*
How would you rate the patient's fatigue over the past week?
*
No fatigue
0
1
2
3
4
5
6
7
8
9
Extreme fatigue
10
0 is No fatigue, 10 is Extreme fatigue
Has the patient experienced any of the following symptoms in the past week? (Select all that apply)
*
Shortness of breath
Dizziness or lightheadedness
Pale skin
Chest pain
Rapid heartbeat
None of the above
Has the patient received a blood transfusion in the past month?
*
Yes
No
Unknown
Is the patient currently receiving erythropoiesis-stimulating agents (ESAs)?
*
Yes
No
Unknown
Current Chemotherapy Regimen
*
Please Select
Platinum-based
Taxane-based
Anthracycline-based
Alkylating agents
Other
Unknown
Dietary Intake: Is the patient following any of these dietary patterns?
*
Normal diet
Low iron intake
Vegetarian/Vegan
Other
How much has anemia affected the patient's daily activities?
*
No impact
0
1
2
3
4
5
6
7
8
9
Severe impact
10
0 is No impact, 10 is Severe impact
Submit Assessment
Should be Empty: