Chemotherapy-induced Peripheral Neuropathy Patient Survey

General Information

Question Title

* 1. Do you suffer from Chemotherapy-induced Peripheral Neuropathy (CIPN)?

Yes

Question Title

* 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

Question Title

* 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)

Question Title

* 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)

Question Title

* 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)

Question Title

* 6. What peripheral neuropathy symptoms impact you the most in your daily life?

Temperature sensitivity

Pain

Muscle weakness

Sleeplessness

Tingling

Balance problems

Numbness

Other (please specify)

Question Title

* 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)

Question Title

* 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)

Question Title

* 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)

Question Title

* 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)