Sex

SelectMaleFemale

Patient’s Age

Patient’s Height

Patient’s Weight

Cancer Type

SelectGastrointestinalGenitourinaryOther

Dosage *

SelectStandard DoseDose Reduced

Number of Chemotherapy Agents

SelectPoly-chemo TherapyMono-chemo Therapy

Hemoglobin

Select a value

How is your hearing (with a hearing aid, if needed)?

ChooseExcellentGoodFairPoorTotally Deaf

Number of falls in the past 6 months

Choose1 or moreNone

Can you take your own medicines?

ChooseWithout 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?

ChooseLimited a lotLimited a littleNot 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.)?

ChooseAll of the timeMost of the timeSome of the timeA little of the timeNone of the time

Select Serum Creatinine

Choose0.10.20.30.40.50.60.70.80.911.11.21.31.41.51.61.71.81.922.12.22.32.42.52.62.72.82.933.13.23.33.43.53.63.73.83.944.14.24.34.44.54.64.74.84.955.15.25.35.45.55.65.75.85.96

Creatinine Clearance **

Toxicity Score

Risk of Chemotherapy Toxicity

* Dose delivered with first dose for chemotherapy

** Jeliffe formula