Journal code

Date

Background factors:

Age

Sex

Diagnosis

Number of treatments

Interrupting treatment, cause

Neurotoxic side effects:

Rate

Comments

Sensory

Tingling in hands

Tingling in feet

Numbness in hands

Numbness in feet

Taste changes

Cold sensitivity

Sensitivity to heat

Nerve pain

Motor

Balance difficulty

Muscle weakness

Muscle cramps

Dysphagia

Breathing difficulties

Other