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Living With an Organ Transplant

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Self-Evaluation
Are You Suffering From Medication Side Effects?

This questionnaire will help your transplant team assess certain side effects you may be experiencing with your transplant medications. Please select a number from 1 to 5, with 1 being "never" and 5 being "very often."

Individual results of this self-evaluation will not be stored or collected by WebMD or Novartis Pharmaceuticals Corporation.

1 Since receiving your transplant, have you experienced any of the following symptoms:

a. Heartburn/indigestion
Never

1

2
Often

3

4
Very Often

5
Seperator
b. Bloating
Never

1

2
Often

3

4
Very Often

5
Seperator
c. Stomachache
Never

1

2
Often

3

4
Very Often

5
Seperator
d. Nausea
Never

1

2
Often

3

4
Very Often

5
Seperator
e. Vomiting
Never

1

2
Often

3

4
Very Often

5
Seperator
f. Diarrhea
Never

1

2
Often

3

4
Very Often

5

2Have you experienced any of the above problems within the last 3 months?

Never

1

2
Often

3

4
Very Often

5

3Do these problems ever interfere with eating or cause you to change your diet?

Never

1

2
Often

3

4
Very Often

5

4Do these problems ever interfere with work or physical activity?

Never

1

2
Often

3

4
Very Often

5

5Do these problems ever interfere with social activities or prevent you from enjoying yourself fully at social events?

Never

1

2
Often

3

4
Very Often

5

6Do these problems ever interfere with sleeping?

Never

1

2
Often

3

4
Very Often

5

7How often do you take any medications (Imodium© A-D, Tums© , Rolaids© , Maalox© , Mylanta© , Gaviscon© , Prilosec© , Pepcid© AC, Nexium© , Zantac© )* for these problems?

Never

1

2
Often

3

4
Very Often

5

Question EightHave you ever been tempted to skip a dose or delay time between doses of your transplant medication?

Never

1

2
Often

3

4
Very Often

5

Are there any other comments on your side effects that you would like to discuss with your transplant team? As a reminder, type them in below:

Individual results of this self-evaluation will not be stored or collected by WebMD or Novartis Pharmaceuticals Corporation.

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* Imodium A-D is a registered trademark of McNeil Consumer Healthcare; Tums, Gaviscon, and Zantac are registered trademarks of GlaxoSmithKline; Rolaids is a registered trademark of Pfizer Inc; Maalox is a registered trademark of Novartis Consumer Pharmaceuticals; Mylanta and Pepcid AC are registered trademarks of Johnson & Johnson--Merck Consumer Pharmaceuticals; Prilosec is a registered trademark of Procter & Gamble; Nexium is a registered trademark of AstraZenca LP.

© 2007 Novartis Pharmaceuticals Corporation. All rights reserved.This information is intended for residents of the United States only.

WebMD does not endorse any specific product, service or treatment.


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