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We appreciate you taking a few minutes to complete this evaluation form. Please return it before you leave today. Your feedback is important and will be used to plan services for other patients receiving chemotherapy. Your answers are anonymous.
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| * Are you male or female? |
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| What age group do you belong to? |
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| Rate your level of anxiety on your first day of chemotherapy: |
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| Did you receive chemotherapy education prior to your first infusion day? |
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Rate your knowledge on your first infusion day.
Poor =1, Good = 2 - 4, Excellent =5.
Chemotherapy and how it works: |
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Rate your knowledge on your first infusion day.
Poor =1, Good = 2 - 4, Excellent =5.
The side effects you might experience: |
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Rate your knowledge on your first infusion day.
Poor =1, Good = 2 - 4, Excellent =5.
Actions to take if side effects occur: |
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Rate your knowledge on your first infusion day.
Poor =1, Good = 2 - 4, Excellent =5.
When to contact a health care professional: |
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Rate your knowledge on your first infusion day.
Poor =1, Good = 2 - 4, Excellent =5.
How the healthcare team can support you during your treatment: |
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