| My Gender: |
Male/female |
| My lymphoma treatment history: |
Untreated
Once-treated with Rituxan
Once-treated with Rituxan and chemo
Once-treated with Radioimmunotherapy
Treated more than once with Rituxan only
Treated more than once, including Rituxan and chemo
|
Time since last therapy for lymphoma
(select closest that applies) |
Never treated |I'm in treatment now | 1 to 3 weeks ago | 1 to 3 months | 6 months to a year | 1.5 years | 2 or more years. |
| Age at diagnosis? |
|
| Approximate number of years since diagnosis? |
Newly diagnosed | 1 to 3 weeks ago | 1 to 3 months | 6 months to a year | 1.5 years | 2 ... 25 |
| My current stage of lymphoma: |
In remission (no evidence of disease)
Stage I | II | III | IV | not known |
My bone marrow status:
(from last biopsy) |
% of involvement | not known |
My level of pain from any cause:
|
| No pain |
0 |
| Mild |
1
2
3 |
| Moderate |
4
5
6 |
| Severe |
7
8
9
10 |
|
| The cause of my pain is: |
0 NA (no pain)
1 Lymphoma-related
2 Unrelated to lymphoma
3 Don't know the cause |
I am anemic?
Blood tests show low levels of hemoglobin
(low red blood cell count) |
0 No
1 Yes, mild
2 Yes, Moderate
3 Yes, severe
4 Don't know |
My level of fatigue
just BEFORE I was diagnosed:
|
| Not at all |
0 |
| Mild fatigue |
1
2
3 |
| Moderate fatigue |
4
5
6 |
| Severe fatigue |
7
8
9
10 |
|
My level of fatigue
for PAST THREE WEEKS:
|
| Not at all |
0 |
| Mild fatigue |
1
2
3 |
| Moderate fatigue |
4
5
6 |
| Severe fatigue |
7
8
9
10 |
|
| I've reported fatigue to my doctor? |
No fatigue |
No,
but plan
to ask |
Yes,
without
detail |
Yes,
in detail |
|
| I have been treated for fatigue by my doctor? |
No
fatigue |
No,
but plan
to ask |
Yes,
but not presently |
Yes,
presently |
|
To combat fatigue I have tried:
(check all that apply) |
Anemia medications
Anxiety/mood/depression medications
Exercise on a regular basis
Lymphoma treatment (a factor in deciding to treat)
Nutritional support
Sleep disorder treatments/medications
Other
|
|
Change in Performance - Mental and Physical
During past THREE WEEKS
|
| It has been challenging to: |
Not at all |
A
little |
Some
what |
Quite
a Bit |
Very
Much |
Eat normally?
(eat too much or too little) |
0 |
1 |
2 |
3 |
4 |
Speak or move normally
or have been excessively fidgety (restless)? |
0 |
1 |
2 |
3 |
4 |
Sleep normally?
(sleep too much, or too little): |
0 |
1 |
2 |
3 |
4 |
| Concentrate on tasks normally? |
0 |
1 |
2 |
3 |
4 |
Take part in regular activities
from lack of desire/motivation?
(I have lower motivation to do what I did before: socialize, do hobbies, read paper,
watch TV, exercise) |
0 |
1 |
2 |
3 |
4 |
Physically carry out daily activities?
(less able to cook, shop, climb stairs,
take out trash, carry bundles) |
0 |
1 |
2 |
3 |
4 |
|
Change in Mood
During past THREE WEEKS
|
| |
Not at all |
A
little |
Some
what |
Quite
a Bit |
Very
Much |
I feel down, depressed or hopeless?
(feeling sad, despondent, isolated,
or feel suicidal, cry often ...
for an extended period of time) |
0 |
1 |
2 |
3 |
4 |
Have had thoughts that I'd be better off dead
or of hurting yourself? |
0 |
1 |
2 |
3 |
4 |
| I feel that I've let myself or others down? |
0 |
1 |
2 |
3 |
4 |
| |
|
|
|
|
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