• This tool is dedicated to assessing a diagnosed follicular lymphoma patient experience
    with medication related therapies
  • Please follow the questionnaire with your patients to evaluate therapy management
Click Here when Beginning a Patient Discussion


When was your patient diagnosed with follicular lymphoma?

Has your patient experienced any of the following that have affected their current quality of life since diagnosis?
Check all that apply
Fatigue, lack of energy
Enlarged lymph nodes
Frequent infections
Weight loss
Fevers
Pain
Night sweats
Increasing lymphocyte count
Enlarged spleen/discomfort on upper left side of stomach
Shortness of breath
Low IgG levels
Low platelet count (thrombocytopenia)
Anemia (low red blood cells)
Neutropenia (low neutrophils)
General Stress
Depression
Difficulty sleeping
Anxiety/worry
Loss of sexual desire
Memory loss
Problems concentrating
None of the listed symptoms
Other additional symptoms
Has your patient used any of the following treatment regimens for Follicular Lymphoma?
Check all that apply
None [Watch and Wait]
Bendamustine (Treanda) and obinutuzumab (Gazyva)
R-Bendamustine (rituximab [Rituxan] and bendamustine)
R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone)
R-CVP (rituximab, cyclophosphamide, vincristine, and prednisone)
R-Lenalidomide (rituximab and lenalidomide [Revlimid])
Axicabtagene ciloleucel (Yescarta)
Bendamustine (Treanda) with or without rituximab (Rituxan) or obinutuzumab (Gazyva)
Copanlisib (Aliqopa)
Duvelisib (Copiktra)
Fludarabine (Fludara) and rituximab (Rituxan)
Idelalisib (Zydelig)
Lisocabtagene Maraleucel (liso-cel, Breyanzi)
R-FND (rituximab, fludarabine, mitoxantrone, and dexamethasone)
Rituximab
Rituximab and Hyaluronidase Human (Rituxan Hycela)
Tazemetostat (TAZVERIK)
Umbralisib (UKONIQ)

Has the patient experienced any adverse events due to treatment?
Yes No

Has the patient discontinued treatment due to adverse events?
Yes No

Have you discussed with your patient the other potential options to therapy including for relapsed or refractory follicular lymphoma?
Yes No

What does your patient prioritize when considering therapy?
Longer remission than current therapies
Fewer side effects than current therapies
Longer survival than current therapies

Has the patient undergone genetic testing to determine potential treatment?
Yes No
How often does the patient proactively speak with your care team about follow-up appointments and reporting adverse events?
None
1-2 times a month
1-2 times a week
More than twice a week
Which laboratory/imaging tests have been performed to determine response?
Has the patient undergone a PET/CT scan to determine response?
Yes No
What has your patient reported as needs to managing their treatment?
Yes No

Report summary: