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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 (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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