Symptom



Toronto Side Effects Scale

Patient Name_________________________________________ Date:_______________

Within the last 2 weeks, have you had any of the symptoms listed below?

How much trouble did each symptom cause you?

For each symptom, mark how often (frequency) and how bothersome (severity) it is in the boxes below.

Symptom Frequency

| |Never (1) |Sometimes |About half the time |Often (4) |Every |

| | |(2) |(3) | |day (5) |

|Nervousness | | | | | |

|Agitation | | | | | |

|Tremors | | | | | |

|Muscle contraction/ | | | | | |

|Twitching (myoclonus) | | | | | |

|Abdominal pain | | | | | |

|Upset Stomach | | | | | |

|Nausea | | | | | |

|Diarrhea | | | | | |

|Constipation | | | | | |

|Decreased appetite | | | | | |

|Increased appetite | | | | | |

|Weakness or fatigue | | | | | |

|Dizziness | | | | | |

|Dizzy when getting up | | | | | |

|(postural hypotension) | | | | | |

|Drowsiness/daytime sleepiness | | | | | |

|Increased sleep | | | | | |

|Decreased sleep | | | | | |

|Sweating | | | | | |

|Flushing | | | | | |

|Fluid retention (edema) | | | | | |

|Headache | | | | | |

|Blurred vision | | | | | |

|Dry mouth | | | | | |

|No orgasm (anorgasmia) | | | | | |

|Increased libido | | | | | |

|Decreased libido | | | | | |

|Other, specify: | | | | | |

|Weight gain |None |< 2 lb |< 4 lb |< 6 lb |< 7 lb |

|Weight loss |None |< 2 lb |< 4 lb |< 6 lb |< 7 lb |

| | | | | | |

Men only

| | 1 | 2 | 3 | 4 | 5 |

|Premature ejaculation | | | | | |

|Delayed ejaculation | | | | | |

|Erectile dysfunction | | | | | |

Patient Name_________________________________________ Date:_______________

Symptom Severity

| |No Trouble (1) |Some Trouble |Moderate Trouble |More Trouble |Extreme Trouble|

| | |(2) |(3) |(4) |(5) |

|Nervousness | | | | | |

|Agitation | | | | | |

|Tremors | | | | | |

|Muscle contraction/ | | | | | |

|Twitching (myoclonus) | | | | | |

|Abdominal pain | | | | | |

|Upset Stomach | | | | | |

|Nausea | | | | | |

|Diarrhea | | | | | |

|Constipation | | | | | |

|Decreased appetite | | | | | |

|Increased appetite | | | | | |

|Weakness or fatigue | | | | | |

|Dizziness | | | | | |

|Dizzy when getting up | | | | | |

|(postural hypotension) | | | | | |

|Drowsiness/daytime sleepiness | | | | | |

|Increased sleep | | | | | |

|Decreased sleep | | | | | |

|Sweating | | | | | |

|Flushing | | | | | |

|Fluid retention (edema) | | | | | |

|Headache | | | | | |

|Blurred vision | | | | | |

|Dry mouth | | | | | |

|No orgasm (anorgasmia) | | | | | |

|Increased libido | | | | | |

|Decreased libido | | | | | |

|Other, specify: | | | | | |

|Weight gain | | | | | |

|Weight loss | | | | | |

| | | | | | |

Men only

| | 1 | 2 | 3 | 4 | 5 |

|Premature ejaculation | | | | | |

|Delayed ejaculation | | | | | |

|Erectile dysfunction | | | | | |

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