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Follow up sheet for SI B protocol
Date:
Name:
RT number:
KPS:
Pain
\ue000 No pain
\ue000 Mild pain , no medication
\ue000 Moderate pain , regular meds
\ue000 Severe pain , regular narcotic
\ue000 Severe pain , not controlled
Appearance
\ue000 No change
\ue000 Minor change
\ue000 Bothersome but remain active
\ue000 Limited activity & disfigured
\ue000 Cannot be with people
Activity
\ue000 As active as ever
\ue000 Reduced but infrequent disruption
\ue000 Often tired & Slowed down
\ue000 Lack strength to go out
\ue000 Confined to home (bed/chair)
Recreation
\ue000 No limits
\ue000 Few limitations in \u201cgoing out\u201d
\ue000 Many times not going out
\ue000 Severe limitations
\ue000 Cant do anything enjoyable
Mood
\ue000 Ex cellen t
\ue000 Good , occasionally affected
\ue000 Not in good mood nor depressed \ue000 Somewhat depressed
\ue000 Extremely depressed
Speech
\ue000 Same as always
\ue000 Difficulty but can be understood over phone
\ue000 Only family & friends understand
\ue000 Cannot be understood
Shoulder
\ue000 No problems
\ue000 Stiff but no \ue004 in strength and activity
\ue000 Change in work
\ue000 Cannot work due to shoulder problem
Taste
\ue000 Normal taste
\ue000 Can taste most foods normally
\ue000 Can taste some foods
\ue000 Cannot taste any food
Anxiety
\ue000 Not anxious
\ue000 Little anxious about cancer
\ue000 Anxious about cancer
\ue000 Very anxious about cancer
Saliva
\ue000 Normal consistency
\ue000 Less saliva than normal but sufficient
\ue000 Too little saliva
\ue000 No Saliva
Swallowing
\ue000 Swallow as well as ever\ue000 Cannot swallow certain solids
\ue000 Can swallow only liquid food
\ue000 Cannot swallow as it chokes / goes wrong way
Chewing
\ue000 Chew as well as ever
\ue000 Cannot chew some foods
\ue000 Cannot chew even soft foods
HRQOL w.r.t month before cancer detection
\ue000 Much better
\ue000 Somewhat better \ue000 About the same
\ue000 Somewhat worse
\ue000 Much worse
HRQOL in last week
\ue000 Ou tstand ing
\ue000 Very good
\ue000 Goo d
\ue000 Fair
\ue000 Po or
\ue000 Very Poor
Overall QOL in last week
\ue000 Ou tstand ing
\ue000 Very good
\ue000 Goo d
\ue000 Fair
\ue000 Po or
\ue000 Very Poor
\ue001\ue001 Issues in last 7 days from the 12 items which are most important to the patient (max 3, min 0):
Adverse effect and grade (CTCAE v 3.0) [Use rupee scale for change: (+) = increase (\ue000) / (-) = decrease (\ue001); B = Baseline; Grade independent of scale]
Toxicity
\ue003/\ue002
Gr
Toxicity
\ue003/\ue002
Gr
Toxicity
\ue003/\ue002
Gr
Toxicity
\ue003/\ue002
Gr Toxicity
\ue003/\ue002
Gr
Disease Status:\ue000NED \ue000Local recurrence \ue000Local residual \ue000Nodal recurrence \ue000Nodal residual \ue000Distant metastasis (Tick as many as applicable)
Comments on disease status/ Miscellaneous:
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\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026...\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026
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\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026
\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026
\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026......................................................................................................................................
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Comments on relief obtained from drugs previously prescribed / Serious A/E:
\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026
\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026
\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026............................................................................
Drugs prescribed & Duration:
\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026
\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026................................................
\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026........................
Date for next Follow-up: (dd/mm/yy)
Initials of Investigator
In-treatment Toxicity Chart for SIB IMRT H&N protocol patients (Revised Version 1.0)
Dates\ue002
Week Number
Questions to be asked\ue000
Body Weight (Kg)
PAIN :

Severity of Pain (Mild \u2013 1 , Moderate - 2, Severe - 3)
Pain Medication taken ( No \u2013 0, Yes-1)
Pain relieved by Medication ( No - 0, Yes -1)
Medication ( NSAID -1 , Narcotic -2, Both - 3)
Impairment of Functioning ( No \u2013 0, Yes - 1)
Severely Interfering with ADL ( No \u2013 0, Yes - 1)

% increase (+) / decrease (-) over last assessment\ue001
3 Most Severe Pain sites: (Mouth -1, Jaws -2, Throat -3, Ear -4, Skin -5)
Other site(s) with codes:

Overall CTCAE grade for Pain
DYSPHAGIA (Also includes pain on eating!!):

Severity of Pain on Eating (Mild \u2013 1 , Moderate - 2, Severe - 3)
Food taken ( Solid - 1, Semisolid - 2, Liquid - 3, Tube - 4)
Reduction in Intake due to Pain ( No \u2013 0, Yes - 1)
IV Fluids indicated ( No \u2013 0, <24 hrs - 1, >24 hrs - 2)
Nutritional Supplements ( No \u2013 0, <24 hrs - 1, >24 hrs - 2)
Reason for dysphagia (Mechanical -1, Pain -2 , Both -3)

% increase (+) / decrease (-) over last assessment\ue001
Overall CTCAE Grade for Dysphagia
ANOREXIA :

Present ( No \u2013 0, Yes - 1)
Significant weight loss present ( No \u2013 0, Yes - 1)
Supplements indicated ( None -1, Oral - 2 , TPN / Tube -3)

% increase (+) / decrease (-) over last assessment\ue001
FUNCTIONAL MUCOSITIS :

Intake ( Normal -1, Modified Diet -2, Orally inadequate intake - 3)
Medication Given ( LA =1, Disprin Gargles =2, Steroid =3, Other =4)
Response to Treatment (No \u2013 0, Partial -1, Complete -2 , Progress -4)

% increase (+) / decrease (-) over last assessment\ue001
OTHER SYMPTOMS :

Taste ( All modalities present \u2013 0 , Altered taste -1 , All modalities lost - 2)
Cough (Nil -0, Present -1, Significantly Interfering with Sleep - 2 )
Narcotic Cough Medication ( No \u2013 0, Yes - 1)

% increase (+) / decrease (-) over last assessment\ue001
Hoarseness ( Mild -1 , Occassional repetition -2, Whispered Speech -3)

% increase (+) / decrease (-) over last assessment\ue001
Trismus ( Present -1, Small bites / soft food -2, Inadequate oral intake -3)
Xerostomia ( Present -1, Copious water reqd. -2, Inability to eat per os-3)
Thickened Saliva ( No \u2013 0, Yes - 1)

% increase (+) / decrease (-) over last assessment\ue001
Fatigue (Mild -1, Moderate -2, Severely impaired ADL -3, Disabled -4)
% increase (+) / decrease (-) over last assessment\ue001
Weakness ( Mild -1, Moderate -2, Restricted mobility -3, Bedridden -4)

% increase (+) / decrease (-) over last assessment\ue001
Most Troublesome symptoms reported:
Grade of same:

To be Examined\ue000
Dates\ue002
OBJECTIVE MUCOSITIS GRADING : ( Erythema = E , Ulceration = U , Pseudomembrane = P)

Upper Lip
Lower Lip
Right Cheek
Left Cheek
Dorsal Tongue (Rt)
Dorsal Tongue (Lt)
Floor of Mouth (Rt)

Floor of Mouth (Lt)

Hard Palate
Soft Palate
Fauces and Pillar (Rt)
Fauces and Pillar (Lt)
Posterior Pharynx

Ulceration / Pseudomembrane: No leison = 0; < 1 cm2 = 1; 1 cm2 to 3 cm2 = 2; > 3 cm2 = 3
Erythema:None = 0; Not Severe = 1; Severe= 2
1cm Scale
Objective CTCAE Grade (Oral Mucosa)
Objective CTCAE Grade (Pharynx)
OBJECTIVE DERMATITIS GRADING : (0 = No leison; 1 = Longest diameter < 3 cm; 2 = Longest diameter 3 \u2013 6 cm; 3 = Longest diameter > 6 cm)

Face
Right Neck
Left Neck
Severest Dermatitis Grade :
Medication give ( GV paint =1 , Steroids = 3, Cansafe =3)
Response to medication ( No \u2013 0, Yes - 1)

Grade( Erythema =1 , Patchy moist desquamation in folds or dry desquamation = 2, Moist desquamation in areas other than folds = 3 , Necrosis / Ulceration = 4)
ADL: The performance of the basic activities of self care; getting in and out of bed, dressing, eating, and getting around inside, dressing, bathing and using the toilet. How do the symptoms affect his/her ability to care for
self, to move about, to do what he/she would do if able?Impairment of Functioning: Signs or symptoms that either prevents a part of the body to perform its action, or that intervenes/intrudes upon the normal physiologic
property of an organ or other part of the body.
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