Select the language
English Spanish Chinese Japanese Korean Armenian Farsi Arabic Tagalog Vietnamese French Portuguese
Patient’s Height
Select Inches Centimeters
Patient’s Weight
Select Pounds Kilograms
Cancer Type
Select Gastrointestinal Genitourinary Other
Dosage *
Select Standard Dose Dose Reduced
Number of Chemotherapy Agents
Select Poly-chemo Therapy Mono-chemo Therapy
Hemoglobin
Select a value
How is your hearing (with a hearing aid, if needed)?
Choose Excellent Good Fair Poor Totally Deaf
Number of falls in the past 6 months
Choose 1 or more None
Can you take your own medicines?
Choose Without help (in the right doses at the right time) With some help (able to take medicine if someone prepares it for you and/or reminds you to take it) Completely unable to take your medicines
Does your health limit you in walking one block?
Choose Limited a lot Limited a little Not limited at all
During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?
Choose All of the time Most of the time Some of the time A little of the time None of the time
Select Serum Creatinine
Choose 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 3 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 4 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 5 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 6
Calculate Toxicity Score
What does this mean?
* Dose delivered with first dose for chemotherapy
