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<p>
<b>Chronic Myeloid Leukaemia Symptom Questionnaire</b>
</p>
<p>
<u>Symptoms which can be associated with disease activity:</u>
</p>
<p>
<b>Bone pain</b>: aching/discomfort in one or more bones, not
arthritic or muscular aches.<br />
<b>Abdominal pain</b>: aching sensation in the abdomen/stomach, not
mild upset.
</p>
<p class="indent">
Do you have any bone or abdominal pain�� YES [ ]�� NO [ ]
</p>
<p class="indent">
If yes, is the pain: Long-standing but stable [ ]���
New, or� long-standing but getting worse [ ]
</p>
<p align="right">
If yes, is the pain in the: Ribs [ ]��� Back [ ]��� Upper Arms [ ]���
Upper Legs [ ] Abdomen [ ] Other [ ]
</p>
<p>
<b>Weight loss</b>: unexplained loss of 10% or more body weight
without dieting.
</p>
<p class="indent">
Have you lost weight in the last six months: �� YES [ ]�� NO [ ]
</p>
<p>
<b>Night Sweats</b>: significant night time sweating that soaks the
bedclothes and bedding.
</p>
<p class="indent">
Do you have night sweats: ���No [ ]��� Occasionally [ ]��� Often [ ]���
Often, drenching sweats [ ]
</p>
<p>
<u>Your stock of Imatinib/Glivec/Nilotinib/Dasatinib/Interferon (please delete as appropriate)</u>
</p>
<p>
We would like you to tell us how much stock you have:
<div>................ tablets ............... dosage per tablet</div>
</p>
<p class="red">IF YOU HAVE LESS THAN ONE MONTH SUPPLY PLEASE CALL US IMMEDIATELY</p>
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<p>
<div>
<b>If you develop one of these symptoms, or a pre-existing symptom
becomes significantly worse, please contact:</b>
</div>
<div>Alison Chatten: 0113 2068337 email: alison.chatten@leedsth.nhs.uk</div>
<div> Andy Rawstron: 0113 2067851 email: andy.rawstron@nhs.net</div>
</p>
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