PREDICTION TOOL
Gender:
Patient's Age:
Patient's Height:  
Patient's Weight:  
Cancer Type:
Dosage:  *
Number of chemotherapy agents:
Hemoglobin:
How is your hearing (with a hearing aid, if needed)?:
Number of falls in the past 6 months:
Can you take your own medicines?:
Does your health limit you in walking one block?:
During the past 4 weeks, how much of the time has
your physical health or emotional problems interfered
with your social activities (like visiting
with friends, relatives, etc.)?:
Select Serum Creatinine:
Creatinine Clearance:  **
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Toxicity Score:
Risk of Chemotherapy Toxicity:
  What does this mean?
  * Dose delivered with first dose for chemotherapy
  ** Jeliffe formula