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| ‰RO R)(42(<-.5) O0-0+*                                                                           | '                        | '"    |    | 'S    |
| Š)+(232:65 …†-<                                                                           | '                        | '"    |    | 'S    |
| Q, /644)().06-3, '3-0)3)0*                                                                           | '‹                        | '‹    | 'Œ    | '    |
| Ž' 'Ž""•"–— ˜Ž™š ›œI ƒFJ                                                                           | '                        |    | ' Œ    | '    |
| R8, R88, PŠž                                                                           | '                        |    |    |    |
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| O¡8 DNO8F, 820-3  Q636(+E6.                                                                           | '                        | '?    | 'Œ    | '    |
| LžP ƒ)-/ -./ 2( O'6.)  D6.53+/6.: /644+*62.,  ')(4+*62. -./ *')50(2*52'=F  2( 8                                                                           | '                        | '"    |    | ' ¢    |
| LMNOP O=<'02<  N**)**<).0                                                 | '                        | '"    |    | ' S    |
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untitled h1
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untitled h1
md anderson symptom inventory -

Part I. How severe are your symptoms?  
People with cancer frequently have symptoms that are caused by their disease or by their treatment. We ask you to rate how severe the following symptoms have been in the last 24 hours. Please select a number from 0  
| (symptom has not been present) to 10 (the symptom was as bad as you can imagine it could be) for each item.   |                             |    |    |    |    |    |    |    |    |    |    |    |
|---------------------------------------------------------------------------------------------------------------|-----------------------------|----|----|----|----|----|----|----|----|----|----|----|
| As Bad As You                                                                                                 |                             |    |    |    |    |    |    |    |    |    |    |    |
| Not                                                                                                           |                             |    |    |    |    |    |    |    |    |    |    |    |
| Present                                                                                                       | Can Imagine                 |    |    |    |    |    |    |    |    |    |    |    |
| 0                                                                                                             | 1                           | 2  | 3  | 4  | 5  | 6  | 7  | 8  | 9  | 10 |    |    |
| Your pain at its WORST?                                                                                       |                             |    |    |    |    |    |    |    |    |    |    |    |
| 1.                                                                                                            | o                           | o  | o  | o  | o  | o  | o  | o  | o  | o  |    |    |
| 2.                                                                                                            | Your fatigue (tiredness) at | o  | O  | O  | o  | o  | o  | o  | o  | o  | O  | o  |
| its WORST?                                                                                                    |                             |    |    |    |    |    |    |    |    |    |    |    |
| Your nausea at its WORST?                                                                                     |                             |    |    |    |    |    |    |    |    |    |    |    |
| 3.                                                                                                            | O                           | o  | O  | o  | o  | o  | o  | O  | o  | o  | o  |    |
| 4.                                                                                                            | Your disturbed sleep at its | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| WORST?                                                                                                        |                             |    |    |    |    |    |    |    |    |    |    |    |
| 5.                                                                                                            | Your feelings of being      | o  |    |    |    |    |    |    |    |    |    |    |
| distressed (upset) at its                                                                                     | O                           | o  | O  | o  | o  | o  | O  | O  | o  | o  |    |    |
| WORST?                                                                                                        |                             |    |    |    |    |    |    |    |    |    |    |    |
| 6.                                                                                                            | Your shortness of breath at | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| its WORST?                                                                                                    |                             |    |    |    |    |    |    |    |    |    |    |    |
| 7.                                                                                                            | Your problem with           |    |    |    |    |    |    |    |    |    |    |    |
| remembering things at its                                                                                     | o                           | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |    |
| WORST?                                                                                                        |                             |    |    |    |    |    |    |    |    |    |    |    |
| 8.                                                                                                            | Your problem with lack of   | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| appetite at its WORST?                                                                                        |                             |    |    |    |    |    |    |    |    |    |    |    |
| 9.                                                                                                            | Your feeling drowsy         | o  |    |    |    |    |    |    |    |    |    |    |
| o                                                                                                             | o                           | o  | o  | o  | o  | o  | o  | o  | o  |    |    |    |
| (sleepy) at its WORST?                                                                                        |                             |    |    |    |    |    |    |    |    |    |    |    |
| 10. Your having a dry mouth at                                                                                | o                           | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |    |
| its WORST?                                                                                                    |                             |    |    |    |    |    |    |    |    |    |    |    |
| 1. Your feeling sad at its                                                                                    | O                           | o  | o  | o  | o  | o  |    |    |    |    |    |    |
| o                                                                                                             | o                           | O  | O  | o  |    |    |    |    |    |    |    |    |
| WORST?                                                                                                        |                             |    |    |    |    |    |    |    |    |    |    |    |
| 12. Your vomiting at its                                                                                      | o                           | o  | o  | o  | o  | o  | o  | O  | o  |    |    |    |
| o                                                                                                             | o                           |    |    |    |    |    |    |    |    |    |    |    |
| WORST?                                                                                                        |                             |    |    |    |    |    |    |    |    |    |    |    |
| 13. Your numbness or tingling                                                                                 | O                           | o  | o  | o  | o  | O  | o  | o  | o  |    |    |    |
| o                                                                                                             | o                           |    |    |    |    |    |    |    |    |    |    |    |
| at its WORST?                                                                                                 |                             |    |    |    |    |    |    |    |    |    |    |    |
| 14. Your weakness on one side                                                                                 | o                           | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |    |
| of the body at its WORST?                                                                                     |                             |    |    |    |    |    |    |    |    |    |    |    |
| 15. Your difficulty                                                                                           |                             |    |    |    |    |    |    |    |    |    |    |    |
| understanding at its                                                                                          | O                           | o  | o  | O  | o  | o  | o  | o  | O  | o  | o  |    |
| WORST?                                                                                                        |                             |    |    |    |    |    |    |    |    |    |    |    |
| 16. Your difficulty speaking                                                                                  | o                           | o  | O  | o  | o  | o  | O  | o  | o  | O  | o  |    |
| (finding the words) at its                                                                                    |                             |    |    |    |    |    |    |    |    |    |    |    |
| WORST?                                                                                                        |                             |    |    |    |    |    |    |    |    |    |    |    |  
Institution:
Hospital Chart \#:
Date:
Participant Initials:
Institution:
Hospital Chart \#:
Participant Number:  
| Not                               | As Bad As You   |    |    |    |    |    |    |    |    |    |    |
|-----------------------------------|-----------------|----|----|----|----|----|----|----|----|----|----|
| Present                           | Can Imagine     |    |    |    |    |    |    |    |    |    |    |
| 0                                 | 1               | 2  | 3  | 4  | 5  | 6  | 7  | 8  | 9  | 10 |    |
| 17. Your seizures at its WORST?   | o               | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| 18. Your difficulty concentrating | o               | o  | o  | O  | o  | o  | o  | o  | o  | o  | O  |
| at its WORST?                     |                 |    |    |    |    |    |    |    |    |    |    |
| 19.  Your vision at its WORST?    | o               | o  | o  | o  | o  | o  | o  | o  | O  | o  | o  |
| 20. Your change in appearance     | O               | o  | o  | o  | o  | o  | O  | o  | O  | o  | o  |
| at its WORST?                     |                 |    |    |    |    |    |    |    |    |    |    |
| 21. Your change in bowel pattern  |                 |    |    |    |    |    |    |    |    |    |    |
| (diarrhea or constipation) at     | o               | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| its WORST?                        |                 |    |    |    |    |    |    |    |    |    |    |
| 2.  Your irritability at its      | o               | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| WORST?                            |                 |    |    |    |    |    |    |    |    |    |    |  
Part II. How have your symptoms interfered with your life? Symptoms frequently interfere with how we feel and function. How much have your symptoms interfered with the following items in the last 24 hours?  Please select a number from 0 (symptoms have not interfered) to 10 (symptoms interfered completely) for each item.  
| Did Not                  | Interfered   |    |    |    |    |    |    |    |    |    |    |
|--------------------------|--------------|----|----|----|----|----|----|----|----|----|----|
| Interfere                | Completely   |    |    |    |    |    |    |    |    |    |    |
| 0                        | 3            | 5  | 6  | 8  | 9  | 10 |    |    |    |    |    |
| 1                        | 2            | 4  | 7  |    |    |    |    |    |    |    |    |
| 2. General activity?     | o            | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| 2. Mood?                 | o            | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| 25. Work (including work | o            | o  | o  | o  | O  | O  | o  | o  | o  | o  | o  |
| around the house)?       |              |    |    |    |    |    |    |    |    |    |    |
| 26. Relations with other | o            | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| people?                  |              |    |    |    |    |    |    |    |    |    |    |
| 2. Walking?              | o            | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| 2.  Enjoyment of life?   | o            | o  | o  | o  | o  | o  | O  | o  | o  | o  | o  |
untitled h1
m. d. anderson symptom inventory

Part I. How severe are your symptoms? People with cancer frequently have symptoms that are caused by their disease or by their treatment. We ask you to rate how severe the following symptoms have been in the last 24 hours. Please fill in the circle below from 0 (symptom has not been present) to 10 (the symptom was as bad as you can imagine it could  
| below from 0 (symptom has not been present) to 10 (the symptom was as bad as you can imagine it could   |             |               |    |    |    |    |    |    |    |    |    |    |
|---------------------------------------------------------------------------------------------------------|-------------|---------------|----|----|----|----|----|----|----|----|----|----|
| be) for each item.                                                                                      | Not         | As Bad As You |    |    |    |    |    |    |    |    |    |    |
| Presen                                                                                                  | Can Imaging |               |    |    |    |    |    |    |    |    |    |    |
| CORE Items                                                                                              | 0           | 1             | 2  | 3  | .4 | 5  | 6  | 7  | 88 | 9  | 10 |    |
| 1. Your pain at its WORST?                                                                              | O           | o             |    |    |    |    |    |    |    |    |    |    |
| o                                                                                                       | o           | o             | o  | o  | o  | o  | o  | o  |    |    |    |    |
| 2. Your fatigue (tiredness) at                                                                          | o           | o             | o  | O  | o  | o  | o  | o  | o  |    |    |    |
| o                                                                                                       | o           |               |    |    |    |    |    |    |    |    |    |    |
| its WORST?                                                                                              |             |               |    |    |    |    |    |    |    |    |    |    |
| 3. Your nausea at its WORST?                                                                            | o           | o             | o  | o  | o  | o  | o  | o  | o  | O  | o  |    |
| 4. Your disturbed sleep at its                                                                          | o           | o             | o  | o  | o  | o  | o  | o  | o  |    |    |    |
| o                                                                                                       | o           |               |    |    |    |    |    |    |    |    |    |    |
| WORST?                                                                                                  |             |               |    |    |    |    |    |    |    |    |    |    |
| 5. Your feeling of being distressed                                                                     |             |               |    |    |    |    |    |    |    |    |    |    |
| (upset) at its WORST?                                                                                   | o           | o             | o  | o  | o  | o  | o  | o  | o  | o  | O  |    |
| 6.                                                                                                      | Your shortness of breath at its
WORST?             | O             | o  | o  | O  | o  | O  | o  | o  | o  | o  | o  |
| 7. Your problem with remembering                                                                        | o           | o             | o  | o  | o  | o  | O  | O  | o  | O  | o  |    |
| things at its WORST?                                                                                    |             |               |    |    |    |    |    |    |    |    |    |    |
| 8. Your problem with lack of appetite                                                                   | o           | o             | o  | o  | O  | o  | O  | o  | o  | o  | o  |    |
| at its WORST?                                                                                           |             |               |    |    |    |    |    |    |    |    |    |    |
| 9.  Your feeling drowsy (sleepy) at                                                                     | O           | o             | o  | o  | o  | o  | o  | o  | O  | o  | o  |    |
| its WORST?                                                                                              |             |               |    |    |    |    |    |    |    |    |    |    |
| 10.                                                                                                     | Your having a dry mouth at its
WORST?             | o             | o  | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| 1. Your feeling sad at its WORST?                                                                       | O           | o             | O  | o  | o  | O  | o  | o  | o  | o  | O  |    |
| 12. Your vomiting at its WORST?                                                                         | o           | O             | o  | o  | o  | o  | O  | o  | o  | o  | o  |    |
| 13. Your numbness or tingling at                                                                        | o           | o             | o  | o  | o  | o  | o  | o  |    |    |    |    |
| O                                                                                                       | o           | o             |    |    |    |    |    |    |    |    |    |    |
| its WORST?                                                                                              |             |               |    |    |    |    |    |    |    |    |    |    |  
Page 1 of 2 Copyright 2000 The University of Texas M. D. Anderson Cancer Center All rights reserved.  
| 19. General activity?            |
|----------------------------------|
| 2. Mood?                         |
| 21.  Work (including work around |
| the house)?                      |
| 2. Relations with other people?  |
| 2. Walking?                      |
| 2.  Enjoyment of life?           |  
Date:
Participant Initials:
Institution:
Hospital Chart \#:
Participant Number:  
| As Bad As You                     |         |             |    |    |    |    |    |    |    |    |    |
|-----------------------------------|---------|-------------|----|----|----|----|----|----|----|----|----|
| Not                               |         |             |    |    |    |    |    |    |    |    |    |
| SPINE Tumor Specific Items        | Present | Can Imagine |    |    |    |    |    |    |    |    |    |
| 0                                 | 2       | 3           | 4  | 5  | 7  | 8  | g  |    |    |    |    |
| 6                                 | 10      |             |    |    |    |    |    |    |    |    |    |
| 1. Your radiating spine pain      | o       | o           | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| at its WORST?                     |         |             |    |    |    |    |    |    |    |    |    |
| 15. Your weakness in the arms     | o       | o           | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| and/or legs at its WORST?         |         |             |    |    |    |    |    |    |    |    |    |
| 16. Your loss of control of bowel | o       | o           | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| and/or bladder at its WORST?      |         |             |    |    |    |    |    |    |    |    |    |
| 17. Your change in bowel pattern  | o       | o           | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| (diarrhea/constipation) at its    |         |             |    |    |    |    |    |    |    |    |    |
| WORST?                            |         |             |    |    |    |    |    |    |    |    |    |
| 18. Your sexual function          | o       | o           | o  | o  | o  | o  | o  | o  | o  | o  | o  |
| at its WORST?                     |         |             |    |    |    |    |    |    |    |    |    |  
Part II. How have your symptoms interfered with your life?  
Symptoms frequently interfere with how we feel and function. How much have your symptoms interfered with the following items in the last 24 hours:
Page 2 of 2 Copyright 2000 The University of Texas M. D. Anderson Cancer Center All rights reserved.  
MDASI-SP - 2010  
| Did not   | interfered   |    |    |    |    |    |    |    |    |    |
|-----------|--------------|----|----|----|----|----|----|----|----|----|
| Interfere | Completely   |    |    |    |    |    |    |    |    |    |
| o         | 2            | 3  | -  | S  | 6  | 7  | 8  | g  | 10 |    |
| o         | o            | o  | o  | o  | o  | o  | o  | o  | o  | o  |
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