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HORMONE THERAPY SIDE EFFECTS NAIRE Are you

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					           HORMONE THERAPY SIDE EFFECTS
                 QUESTIONNAIRE

    Are you taking Tamoxifen, Arimidex, Femara or Aromasin?
       Your oncologist would like to know about any side effects you may be
experiencing. Please fill out this brief questionnaire. It can be sent to your doctor
through email by copying and pasting into a secure message at kp.org. Or, you
can bring it with you to your next appointment. This information will help you and
your oncologist to make better decisions about your therapy.

   1. Do you have hot flashes?

          a. How many times a day?

          b. Do your hot flashes keep you from doing your regular daily
             activities?

   2. Do you have new joint pain since starting the medication?

          a. Where are your joint pains (for example: hands, wrists, knees,
             etc.)?

          b. Would you rate these pains as mild, moderate or severe?

   3. Do you have vaginal irritation or dryness?

          a. Would you rate this as mild, moderate or severe?

          b. Do you have pain or discomfort with intercourse?

          c. Do you have vaginal bleeding or spotting?

   4. Have you gained weight since taking this medication?

          a. How many pounds have you gained?

Do you have any other side effects you would like to report to your oncologist?

				
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