Have you had Nausea/Vomiting?
Yes, within the Last 24 hours of receiving chemotherapy Yes, within the 2nd day to the 4th day after chemotherapy

Nausea and Vomiting during the first 24 hours after chemotherapy:

In the 24 hours since chemotherapy, did you have any vomiting?
Yes No

If you vomited in the 24 hours since chemotherapy, how many episodes did you have? (episodes separated by every 5 minutes) (Number 0-50)
In the 24 hours since chemotherapy, did you have any nausea?
Yes No

If you had nausea, please enter the number (between 1-10) that most closely resembles your experience. 1= None 10= Severe (as much as possible)
Were you given Pre-medication (Intravenous) or Rescue Medications (Oral)?
Yes (Pre-meds) Yes (Rescue) Yes (Both)

Did you feel the medications improved your symptoms?
Yes No

Did you (as the patient) require a return visit to the clinic for hydration for nausea/vomiting?
Yes No

Did you (as the patient) have to stay/be admitted to a facility (ex. Emergency department or Hospital) for hydration/electrolyte replacement to help control symptoms
Yes No

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Nausea and Vomiting after the first 24 hours of chemotherapy (2-4 days after chemotherapy)


Please fill in the date when this form was filled out:
Date:
Month:
Day of the Week:
Did you vomit more than a day after chemotherapy?
Yes No

How many times did you vomit after the first 24 hours of chemotherapy? (Number 0-50)

How many episodes did you have per 24 hour period? (episodes separated by 5 minutes) (Number 0-50)

Did you have any nausea more than a day after chemotherapy?
Yes No

If you had nausea, please enter the number (between 1-10) that most closely resembles your experience. 1= None 10= Severe (as much as possible)

Were you given Pre-medication (Intravenous) or Rescue Medications (Oral)?
Yes (Pre-meds) Yes (Rescue) Yes (Both)

Did you feel the medications improved your symptoms?
Yes No

Did you (as the patient) require a return visit to the clinic for hydration for nausea/vomiting?
Yes No

Did you (as the patient) have to stay/be admitted to a facility (ex. Emergency department or Hospital) for hydration/electrolyte replacement to help control symptoms
Yes No

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