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Table 3 Questionnaire documenting oral or facial symptoms of acute and chronic neuropathy experienced during or after oxaliplatin-based chemotherapy.

From: Survey of oxaliplatin-associated neurotoxicity using an interview-based questionnaire in patients with metastatic colorectal cancer

Oral/Facial Symptoms    If you had symptoms during the last cycle....
    How much of the symptoms did you have? Did the symptoms affect your daily activities?
Do you have....    Hardly any → Very much Hardly at all bothered → Extremely bothered
Jaw pain Yes No 1 2 3 4 5 1 2 3 4 5
Eyelids drooping Yes No 1 2 3 4 5 1 2 3 4 5
Throat discomfort Yes No 1 2 3 4 5 1 2 3 4 5
Ear pain Yes No 1 2 3 4 5 1 2 3 4 5
Tingling in mouth Yes No 1 2 3 4 5 1 2 3 4 5
Difficulty with speech Yes No 1 2 3 4 5 1 2 3 4 5
Burning or discomfort of your eyes Yes No 1 2 3 4 5 1 2 3 4 5
Loss of any vision Yes No 1 2 3 4 5 1 2 3 4 5
Feeling shock/pain down back Yes No 1 2 3 4 5 1 2 3 4 5
Problems with breathing Yes No 1 2 3 4 5 1 2 3 4 5
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