DOI: 10.3310/hta17260 HEALTH TECHNOLOGY ASSESSMENT 2013  VOL. 17 NO.

26

Instructions:

Please mark the box for each question that most clearly corresponds to your experience. Please do not miss
out a question and place only one X in a box for each question. e.g. The ____ in statements represents
the selected phrase.

Day before chemotherapy Day 3 after chemotherapy

Day of chemotherapy Day 4 after chemotherapy
Day 1 after chemotherapy Day 5 after chemotherapy
Day 2 after chemotherapy Day 6 after chemotherapy

1. In the last 12 hours I threw up ____ times: 2. In the last 12 hours, from retching and
dry heaves, I have felt ____ distress:
7 or more no
5-6 mild
3-4 moderate
1-2 great
I did not throw up severe

3. In the last 12 hours, from vomiting or 4. In the last 12 hours, I have felt nauseated
throwing up, I have felt ____ distress: or sick to my stomach:
severe not at all
great 1 hour or less
moderate 2-3 hours
mild 4-6 hours
no more than 6 hours

5. In the last 12 hours, from nausea/sickness 6. In the last 12 hours, each time I threw
to my stomach, I have felt ____ distress: up I produced a ____ amount:
no very large (3 cups or more)
mild large (2-3 cups)
moderate moderate (1/2-2 cups)
great small (up to 1/2 cup)
severe I did not throw up

7. In the last 12 hours, I have felt nauseated 8. In the last 12 hours, I have had periods of retching or
or sick to my stomach ____ times: dry heaves without bringing anything up ____ times:
7 or more no
5-6 1-2
3-4 3-4
1-2 5-6
no 7 or more

d d m m y y y y
Date completed / / Signed _______________________________

ANCHoR.Rhodes v1.0 19/02/2009

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