Anemia Self-Assessment

OrthoBiotech Oncology
Last Modified: January 24, 2002

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If you are overly tired, it might be a sign that you are anemic. After answering the questions below, click the "PRINT" button on your browser to print the results and share them with your doctor.

This survey is for your reference and use. No data is being collected or stored by this site or shared with third parties. Privacy Policy.

Anemia Self-Assessment Form

Since starting chemotherapy, have you had to cut back on everyday activities (grocery shopping, walking the dog, etc.)?
Yes No Somewhat

List two or three activities you can no longer do:

Is this because of weakness or tiredness?
Yes No Somewhat

Before you were diagnosed with cancer, which daily activity did you value the most?

Please rate your ability to do this activity now:
1 = Equally Able, 5 = Not Able
1 2 3 4 5

Are you frustrated by not being able to do the things you want to do?
Yes No Somewhat

Please rate the impact tiredness/weakness has had on your ability to lead a "normal" life:
1= Very Little Impact, 5 = Tremendous Impact
1 2 3 4 5

I am content with the quality of my life right now:
1 = Very Content, 5 = Not Content
1 2 3 4 5

Do you know your hemoglobin (red blood cell) count?
Yes No

If yes, please enter it here:

If no, ask your doctor.


CLEAR

You may also fill this form out offline: Download the Self-Assesment, in Adobe's PDF format.

If you don't have Adobe Acrobat Reader, download it for free.
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