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Clinical Hub,Patient Education,Health and Nutrition Facts For You,Cancer, BMT, Hematology

My Oral Chemotherapy Diary (7776)

My Oral Chemotherapy Diary (7776) - Clinical Hub, Patient Education, Health and Nutrition Facts For You, Cancer, BMT, Hematology

7776


My Oral Chemotherapy Diary
Drug 1 Drug 2
Dosage Dosage
Instructions/
Supportive Care
Instructions/
Supportive Care


DRUG 1 Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Date
Morning
Lunchtime
Evening
Bedtime
Symptoms
DRUG 2 Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
Date
Morning
Lunchtime
Evening
Bedtime
Symptoms
Symptom Codes: C: Constipation D: Diarrhea F: Fatigue (tiredness) HF: Sore hands & feet N: Nausea P: Pain S: Sore Mouth T: Temperature V: Vomiting

Remember!! Side Effects
ξ Take medication as directed by your healthcare team
ξ Use the symptom codes to record any symptoms you experience
ξ Use helpful prompts to remember to take medication (pill boxes etc.)
ξ If you miss a dose, note on diary and call clinic
ξ If you are unable to take medication due to feeling sick, call clinic
ξ Store medication as directed on box or bottle

UW CARBONE CANCER CLINIC CONTACT INFORMATION
PHONE: (608) 265 – 1700
CALL
RIGHT
AWAY
Shivering Episodes Temperature above 38°C (100°F)
Flu like symptoms Bleeding or unusual bruising
Chest pain /difficult breathing Nausea/Vomiting/Diarrhea
Call
within 24
hours
Sore mouth / mouth ulcers Increase in pain
Skin changes (sudden) Constipation
Sore, watery eyes Unsure about treatment plan
Call
within 48
hours
Tiredness
Difficulty coping with treatment Mood changes
Skin changes (gradual)
Your health care team may have given you this information as part of your care. If so, please use it and call if you have any questions. If this information was not given to you as part of your care, please
check with your doctor. This is not medical advice. This is not to be used for diagnosis or treatment of any medical condition. Because each person’s health needs are different, you should talk with your
doctor or others on your health care team when using this information. If you have an emergency, please call 911. Copyright © 5/2015 University of Wisconsin Hospitals and Clinics Authority. All rights
reserved. Produced by the Department of Nursing. HF#7776