Chronic Myeloid Leukaemia Symptom Questionnaire

Symptoms which can be associated with disease activity:

Bone pain: aching/discomfort in one or more bones, not arthritic or muscular aches.
Abdominal pain: aching sensation in the abdomen/stomach, not mild upset.

Do you have any bone or abdominal pain   YES [ ]   NO [ ]

If yes, is the pain: Long-standing but stable [ ]    New, or  long-standing but getting worse [ ]

If yes, is the pain in the: Ribs [ ]    Back [ ]    Upper Arms [ ]    Upper Legs [ ] Abdomen [ ] Other [ ]

Weight loss: unexplained loss of 10% or more body weight without dieting.

Have you lost weight in the last six months:    YES [ ]   NO [ ]

Night Sweats: significant night time sweating that soaks the bedclothes and bedding.

Do you have night sweats:    No [ ]    Occasionally [ ]    Often [ ]    Often, drenching sweats [ ]

Your stock of Imatinib/Glivec/Nilotinib/Dasatinib/Interferon (please delete as appropriate)

We would like you to tell us how much stock you have:

IF YOU HAVE LESS THAN ONE MONTH SUPPLY PLEASE CALL US IMMEDIATELY