Anemia Self-survey

Author: OrthoBiotech Oncology
Last Modified: December 12, 2001

Focus on Fatigue
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[ Fatigue and Cancer ]

[ what is anemia ]

[ are you anemic ]

[ fighting fatigue ]

[ patient packet ]

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On-line Anemia Self-survey

My cancer is (check all that apply):

bone
brain
breast
cervix
colon
leukemia
lymphoma
     lung
mouth/throat
ovary
prostate
skin
stomach
other

1. Since starting chemo, have you had to cut back on everyday activities? (grocery shopping, walking the dog, etc.)

2. List two or three activities you can no longer do.

3. Is this because of weakness or fatigue?

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

5. Please rate your ability to do this activity now.

6. Are you frustrated by not being able to do the things you want to do?

7. Please rate the impact tiredness/weakness has had on your ability to lead a "normal" life.

8. I am content with the quality of my life right now.

Thank you! Now just hit the Submit button to continue.



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