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New Patient Assessment
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Rick Simpson Oil Cancer Study
New Patient Assessment
New Patient Assessment
MyMJStory
2020-01-06T03:40:04-07:00
1
Patient Info
2
Medication Info
3
Side Effects
Patient ID Number
Weight
Daily Notes
Updated Blood Results?
Have new blood work? Click Yes to enter the results
Yes
Blood Work
Lab Test
ANC
Hematocrit
Hemoglobin
Lab Test
Platelets
Red Cells
White Cells
RSO Oil Dosage
Be sure to include all of your dosages
Time
Amount Taken
How Taken
Chemo Dosage
Record your chemotherapy treatments here
Time
Type
Amount Taken
Other Medication
Medicine List
Be sure to list everything you tak including things like vitamins, herbs and other supplements. Be sure to include "as needed" items like aspirin and allergy medication.
Time
Drug or Supplement
Amount Taken
Side Effects
You may have none, some, or all of these, or you may have side effects not listed here.
Fever/Chills:
Record your highest temperature for the day.
None – Temperature 98.6° F
Mild – Fever 98.6° F to 100.4° F
Moderate – Fever 100.4° F to 104° F
Severe – Fever greater than 104° F
Fatigue (Feeling Weak):
None
Mild – Able to do normal activities with some effort
Moderate - In bed less than half of the day
Severe - In bed more than half the day
Nausea:
None
Mild - Can eat
Moderate – Eating/drinking less than normal
Severe – Can’t eat or drink
Vomiting:
None
Mild - Vomited once during the day
Moderate - Vomited 2 to 5 times during the day
Severe - Vomited 6 or more times during the day
Sore Mouth
None
Mild - Soreness
Moderate – Soreness of painful ulcer but can eat
Severe - Painful ulcer and cannot eat
Other Side Effects
How many other side effects do you have?
None
One
Two
Three
Side Effect 1
Other Side Effects 1
None
Mild
Moderate
Severe
Side Effect 2
Other Side Effects 2
None
Mild
Moderate
Severe
Side Effect 3
Other Side Effects 3
None
Mild
Moderate
Severe
Phone
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