Side effect self-report 1 | Â | Â | Â | Â | Â | Â | Â | Â |
---|---|---|---|---|---|---|---|---|
Name | Â | Â | Â | Â | Â | Â | Â | Â |
Date | Â | Â | Â | Â | Â | Â | Â | Â |
 | Grade | / | / | / | / | / | / | / |
Stomatitis | Â | Â | Â | Â | Â | Â | Â | Â |
I have stomatitis but it does not hurt | 1 | Â | Â | Â | Â | Â | Â | Â |
Stomatitis hurts a little, but I can eat more than half | 2 | Â | Â | Â | Â | Â | Â | Â |
I can hardly eat because of stomatitis | 3 | Â | Â | Â | Â | Â | Â | Â |
Hand foot syndrome | Â | Â | Â | Â | Â | Â | Â | Â |
Red and swollen, but no pain | 1 | Â | Â | Â | Â | Â | Â | Â |
There is pain, but it does not interfere with daily life | 2 | Â | Â | Â | Â | Â | Â | Â |
It is painful and interferes with daily life | 3 | Â | Â | Â | Â | Â | Â | Â |
Pigmentation | Â | Â | Â | Â | Â | Â | Â | Â |
There is pigmentation in limited areas such as fingertips | 1 | Â | Â | Â | Â | Â | Â | Â |
There is systemic pigmentation | 2 | Â | Â | Â | Â | Â | Â | Â |
Peripheral neuropathy | Â | Â | Â | Â | Â | Â | Â | Â |
There is some numbness, but it does not affect the operation | 1 | Â | Â | Â | Â | Â | Â | Â |
It is difficult to act due to numbness, but it does not interfere with daily life | 2 | Â | Â | Â | Â | Â | Â | Â |
Numbness interferes with daily life | 3 | Â | Â | Â | Â | Â | Â | Â |
I have no sensation | 4 | Â | Â | Â | Â | Â | Â | Â |
Peripheral sensory impairment | Â | Â | Â | Â | Â | Â | Â | Â |
I react instantly to hypersensitivity when I come in contact with cold things | 1 | Â | Â | Â | Â | Â | Â | Â |
Contact with cold objects sustains a hypersensitive reaction, but is painless | 2 | Â | Â | Â | Â | Â | Â | Â |
Contact with cold objects causes persistent hypersensitivity and pain | 3 | Â | Â | Â | Â | Â | Â | Â |
 < Please enclose the affected area >  |  |  |  |  |  |  |  |  |