Side effect self-report 2 | 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 | / | / | / | / | / | / | / |
Nausea | Â | Â | Â | Â | Â | Â | Â | Â |
Tolerable | 1 | Â | Â | Â | Â | Â | Â | Â |
If I use anti-nausea drugs, I can manage to eat | 2 | Â | Â | Â | Â | Â | Â | Â |
I can hardly eat because of nausea | 3 | Â | Â | Â | Â | Â | Â | Â |
Anorexia | Â | Â | Â | Â | Â | Â | Â | Â |
I have a slight loss of appetite | 1 | Â | Â | Â | Â | Â | Â | Â |
I can eat somehow | 2 | Â | Â | Â | Â | Â | Â | Â |
I can hardly eat | 3 | Â | Â | Â | Â | Â | Â | Â |
Malaise | Â | Â | Â | Â | Â | Â | Â | Â |
I am a little tired, but it does not interfere with my daily life | 1 | Â | Â | Â | Â | Â | Â | Â |
I often lie down | 2 | Â | Â | Â | Â | Â | Â | Â |
I lie down more often than I am awake | 3 | Â | Â | Â | Â | Â | Â | Â |
Bedridden all day long | 4 | Â | Â | Â | Â | Â | Â | Â |
Diarrhea | Â | Â | Â | Â | Â | Â | Â | Â |
Increased defecation frequency less than 4 times a day compared to usual | 1 | Â | Â | Â | Â | Â | Â | Â |
Increased defecation frequency 4–6 times a day compared to usual | 2 |  |  |  |  |  |  |  |
Increased defecation frequency more than 7 times a day compared to usual | 3 | Â | Â | Â | Â | Â | Â | Â |
If you have any other symptoms of concern, please write them down |