CanConquer

First Name *

Last Name *

Date of Birth *

Symptom Rating

Please rate your current experience of the treatment related symptoms listed below.

0 (None) - 10 (Worst Immaginable)

Fatigue (tiredness)

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Pain

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Breathlessness

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Sleeping issues

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Feelings of distress

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Nausea

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Body weight changed (increase or decrease)

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Changes in Appetite

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Swelling (incl. lymphoedema)

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Scarring

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Altered sensations (hands/feet/other)

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Changes in thinking

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