Patient Identifier

NCI Adverse Events/Symptom Assessment Criteria Grade I Grade II Grade III Grade IV Symptoms but ECOG In bed < 50% of time ambulatory In bed > 50% of time  100% bedridden Oral intake significantly No significant intake, requiring IV Nausea Able to eat decreased fluids ------Requiring parenteral nutrition, or ≥6 episodes in 24 hours over 1 episode in 24 hours 2-5 episodes in 24 hours over physiologic consequences Vomiting pretreatment; or need for IV over pretreatment pretreatment requiring intensive care; fluids hemodynamic collapse Pain (Document Mild-not interfering with Moderate-pain and/or analgesics Severe-pain and/or analgesics Pain Scale and Disabling function interfering but not limiting ADL’s severely interfering with ADL’s details separately)

Oral intake significantly Requiring feeding tube or Anorexia Loss of appetite Requiring IV fluids decreased parenteral nutrition

Increase ≥7 stools/day or Increase of <4 stools Physiologic consequences Increase of 4-6 stools/day, or incontinence; or need for Diarrhea per day over requiring intensive care, or nocturnal stools parenteral support for pretreatment hemodynamic collapse dehydration Requiring stool softener Obstipation requiring manual Constipation Requiring laxatives Obstruction or toxic megacolon or dietary modification evacuation or enema Loss of deep tendon Objective sensory loss or reflexes or paresthesia Neuropathy- paresthesia (including tingling); Sensory loss or paresthesia Permanent sensory loss that (including tingling) but sensory interfering with function, but not interfering with ADL’s interferes with function not interfering with activities of daily living (ADL’s) function Moderate mood alteration Mild mood alteration not Severe mood alteration Suicidal ideation or danger to Mood alteration interfering with function, but not interfering with function interfering with ADL’s self interfering with ADL’s Painless ulcers, Severe ulceration or requires Mucositis (oral, erythema, or mild Painful erythema, edema, or Painful erythema, edema or parenteral or enteral nutritional pharyngeal) soreness in the ulcers, but can eat or swallow ulcers requiring IV hydration support or prophylactic intubation absence of lesions Dyspnea at normal level of Dyspnea at rest or requiring Dyspnea Dyspnea on exertion ------activity ventilator support Increased over Moderate (eg, decrease in Severe (eg, decrease in Fatigue rate: baseline, but not performance status by 1 EOCG performance status by ≥2 ECOG Bedridden or disabling (10) (0-10): altering normal activities level or causing difficulty levels or loss of ability to perform (1-3) performing some activities (4-6) some activities (7-9) Occasional difficulty Difficulty sleeping interfering with Frequent difficulty sleeping, Insomnia sleeping not interfering function but not ADLs interfering with ADL’s ------with function Macular or papular eruption or Severe, generalized Macular or papular erythema with itching or other erythrodema or macular, papular eruption or erythema Generalized exfoliative Rash associated symptoms; localized or vesicular eruption; without associated ulcerative, or bullous determatitis desquamation or other lesions desquamation covering ≥50% symptoms covering <50% of BSA BSA Minimal skin changes or Skin changes, peeling, blisters, Ulcerative dermatitis or skin Rash, Hand-foot dermatitis. Red but not edema, or pain NOT interfering changes with pain interfering skin reaction ------without pain function with function

IV antibiotic,antiviral, Life threatening consequences Infection ------Localized, local intervention interventional radiology or (septic shock, acidosis, ANC <1000 operative intervention hypotension, necrosis)

Liver Dysfunction ------Jaundice Astrixis (Wrist Tremors) Encephalopathy or Coma Liver Failure

Nurse Signature:______Date:______Time:______

Practitioner Supervision:______*1547*

Origin 3/9 Revised 3/14