Chemotherapy Treatment Outcomes Evaluation Form
Please complete this form to evaluate the outcomes of chemotherapy treatment during clinical follow-up. All responses are focused on treatment assessment; do not include personal identifiers.
Treatment Response
*
Complete response
Partial response
Stable disease
Progressive disease
Treatment-Related Side Effects (select all that apply)
*
Nausea/Vomiting
Fatigue
Hair loss
Infection
Neuropathy
Other
Severity of Most Significant Side Effect
*
1
2
3
4
5
Change in Symptoms Since Last Visit
*
Improved
Unchanged
Worsened
Performance Status (ECOG Scale)
*
Please Select
0 - Fully active
1 - Restricted in strenuous activity
2 - Ambulatory, unable to work
3 - Limited self-care
4 - Completely disabled
Quality of Life Assessment
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Hospitalizations or Emergency Visits Since Last Cycle
*
None
Yes, related to treatment
Yes, unrelated to treatment
Laboratory Abnormalities Observed
*
Neutropenia
Anemia
Thrombocytopenia
Renal impairment
Hepatic impairment
None observed
Adverse Events (select all that occurred)
*
Allergic reaction
Mucositis
Cardiac event
Thromboembolism
Other
Follow-up Recommendation
*
Continue current regimen
Modify regimen
Hold treatment
Discontinue treatment
Submit Evaluation
Should be Empty: