Side Effect Checklist

Here you will find a checklist to help you discuss the side effects of your treatment with your healthcare professional or other treatment team members. You can print out the checklist, fill it out, and bring it with you the next time you see your healthcare professional. You should speak with your healthcare professional about any questions you have regarding this checklist or any other side effects that may not be on this list. Working with your healthcare professional and treatment team, you can create the optimal treatment plan personalized for you.

In the past 2 weeks, have you experienced:

General
Blurry vision
Problems with sexual function
Change in breasts
Change in menstrual periods
Headache
Lightheaded, dizziness
Swelling of the hands or feet
High blood pressure
Weight
Lost weight
Gained weight
Gastrointestinal (GI)
Mouth feels too dry
Drooling or too much saliva
Constipation
Nausea
Stomach Ache
Vomiting
Renal and urinary
Unexpected increases in urination, thirst, and/or hunger
Trouble urinating
Urinating frequently
Sleep/fatigue
Sleepiness, sleeping a lot
Trouble getting to sleep or staying asleep
Low energy, easily tired
Muscles and movement
Feeling restless or jittery, cannot sit still
Slowness, trouble getting moving
Muscles feel stiff
Shaking or muscle trembling
Tremor
Muscle pain
Lack of bodily strength
Mental function
Memory problems, forgetfulness
Finding it hard to concentrate
No motivation, loss of interest in usual things
Anxiety
Agitation

YOUR SIDE EFFECTS CHECKLIST:

Doctor, I have experienced the following, which I would like to discuss with you

  • Blurry vision



  • Problems with sexual function



  • Change in breasts



  • Change in menstrual periods



  • Headache



  • Lightheaded, dizziness



  • Swelling of the hands or feet



  • High blood pressure



  • Weight



  • Lost weight



  • Gained weight



  • Mouth feels too dry



  • Drooling or too much saliva



  • Constipation



  • Nausea



  • Stomach Ache



  • Vomiting



  • Unexpected increases in urination, thirst, and/or hunger



  • Trouble urinating



  • Urinating frequently



  • Sleepiness, sleeping a lot



  • Trouble getting to sleep or staying asleep



  • Low energy, easily tired



  • Feeling restless or jittery, cannot sit still



  • Slowness, trouble getting moving



  • Muscles feel stiff



  • Shaking or muscle trembling



  • Tremor



  • Muscle pain



  • Lack of bodily strength



  • Memory problems, forgetfulness



  • Finding it hard to concentrate



  • No motivation, loss of interest in usual things



  • Anxiety



  • Agitation



Other

Any other symptoms (describe other symptoms in the box below):

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