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    CIPN20 English

    Uploaded by

    M Arfat Yameen

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    CIPN20 English

    Uploaded by

    M Arfat Yameen
    14 views2 pages

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    14 views2 pages

    CIPN20 English

    Uploaded by

    M Arfat Yameen

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    ENGLISH

    If you are interested in using the full


    questionnaire or its translations, please
    contact: qlqC30@eortc.org
    EORTC QLQ – CIPN20

    Patients sometimes report that they have the following symptoms or problems. Please indicate the extent
    to which you have experienced these symptoms or problems during the past week. Please answer by
    circling the number that best applies to you.

    During the past week : Not at A Quite Very


    All Little a Bit Much

    31 Did you have tingling fingers or hands? 1 2 3 4

    32 Did you have tingling toes or feet? 1 2 3 4

    33 Did you have numbness in your fingers or hands? 1 2 3 4

    34 Did you have numbness in your toes or feet? 1 2 3 4

    35 Did you have shooting or burning pain in your fingers or hands? 1 2 3 4

    36 Did you have shooting or burning pain in your toes or feet? 1 2 3 4

    37 Did you have cramps in your hands? 1 2 3 4

    38 Did you have cramps in your feet? 1 2 3 4

    39 Did you have problems standing or walking because


    of difficulty feeling the ground under your feet? 1 2 3 4

    40 Did you have difficulty distinguishing


    between hot and cold water? 1 2 3 4

    41 Did you have a problem holding a pen, which


    made writing difficult? 1 2 3 4

    42 Did you have difficulty manipulating small objects with


    your fingers (for example, fastening small buttons)? 1 2 3 4

    43 Did you have difficulty opening a jar or


    bottle because of weakness in your hands? 1 2 3 4

    44 Did you have difficulty walking because your


    feet dropped downwards? 1 2 3 4

    Please go on to the next page


    ENGLISH

    During the past week : Not at A Quite Very


    All Little a Bit Much

    45 Did you have difficulty climbing stairs or getting up


    out of a chair because of weakness in your legs? 1 2 3 4

    46 Were you dizzy when standing up from


    a sitting or lying position? 1 2 3 4

    47 Did you have blurred vision? 1 2 3 4

    48 Did you have difficulty hearing? 1 2 3 4

    Please answer the following question only if you drive a car

    49 Did you have difficulty using the pedals? 1 2 3 4

    Please answer the following question only if you are a man

    50 Did you have difficulty getting or maintaining an erection? 1 2 3 4

     QLQ-CIPN20 Copyright 2003 EORTC Quality of life Group. All rights reserved

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