Skip to content
Chemotherapy-induced Peripheral Neuropathy Patient Survey
General Information
1.
Do you suffer from Chemotherapy-induced Peripheral Neuropathy (CIPN)?
Yes
No
2.
Were you aware that peripheral neuropathy is a common side effect of chemotherapy?
Yes - the medical staff educated and prepared me for potential neuropathy side effects
Yes - through my own research
No - I was not aware chemotherapy could cause peripheral neuropathy
3.
What type of cancer where you diagnosed with?
Bladder Cancer
Breast Cancer
Colon and Rectal Cancer
Endometrial Cancer
Kidney Cancer
Leukemia
Liver Cancer
Lung Cancer
Melanoma
Non-Hodgkin Lymphoma
Pancreatic Cancer
Prostate Cancer
Thyroid Cancer
Ovarian Cancer
Other (please specify)
4.
What chemotherapy drug treatment did your doctor order?
Platinum drugs (cisplatin, carboplatin, oxaliplatin)
Taxanes (paclitaxel/Taxol, docetaxel/Taxotere, cabazitaxel/Jevtana)
Plant alkaloids (vinblastine, vincristine, vinorelbine, etoposide/VP-16)
Immunomodulating drugs (IMiDs, like thalidomide/Thalomid, lenalidomide/Revlimid, and pomalidomide/Pomalyst)
Proteasome inhibitors (bortezomib/Velcade, carfilzomib/Kyprolis, ixazomib/Ninlaro)
Combination treatment
Other (please specify)
5.
On a scale of 1-10 how severe are your peripheral neuropathy symptoms?
0 - Currently symptom free
1 - 3: Minor symptoms on and off
4 - 6: Moderate regular symptoms
7 - 9: Severe frequent symptoms
10: Unbearable constant symptoms
Other (please specify)
6.
What peripheral neuropathy symptoms impact you the most in your daily life?
Numbness
Muscle weakness
Tingling
Temperature sensitivity
Balance problems
Pain
Sleeplessness
Other (please specify)
7.
How soon after chemotherapy treatment did you experience peripheral neuropathy side effects?
Within 1-3 treatments
Within 3-6 treatments
Within 6-12 treatments
After 12 treatments
2-5 years after chemotherapy
Other (please specify)
8.
Were you able to complete your chemotherapy treatment?
Yes - without delay
Yes - after dose reduction/alteration
Yes - after pause/delay
Still in the process of completing chemotherapy
No - unable to complete chemotherapy
Other (please specify)
9.
Did your peripheral neuropathy improve, worsen or disappear after completing chemotherapy treatment?
Symptoms improved
Symptoms did not improve
Symptoms disappeared
Symptoms worsened
Other (Please specify)
10.
What medication do you use to manage your peripheral neuropathy?
Amitriptyline
CBD Oil
Duloxetine
Gabapentanoids
Lidocaine patch
Lyrica
Medical Marijuana
Non-opioid analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs)
None
Opioids
Pain medication
Pregabalin
Topical cream (Voltaren or other)
Vitamin/Herbal Supplements (B12, Turmeric, Magnesium, ALA, etc.)
Other (please specify)
Current Progress,
0 of 10 answered