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Monitoring Ipilimumab + Nivolumab Treatment Diary

IMPORTANT: Please record and report even minor symptoms. All side effects must be reported to your cancer care team.

You are being treated with ipilimumab + nivolumab.
Please use this calendar and please bring to your next appointment

Date of infusion - Cycle _____ (Day 1):

Today’s treatment (check appropriate box):
ipilimumab / nivolumab (every 3w) nivolumab (every 4w)

For the duration of your treatment, please watch for the following side effects and take notes in the “comments” column of
the table below:
Skin: rash, burning, itching, blistering and peeling (palms and soles)

Diarrhea or changes in bowel habits: new diarrhea, pain or cramping in belly, blood in the stool, fever with diarrhea
Breathing: Trouble breathing, dry cough that is new or getting worse, fever
Other: Change in urine colour, nausea, fatigue, headache, dizziness, loss of appetite, changes in taste, vision changes
Also take note of anything new you are concerned about.

Day Date Comments

Example Sept 10 3 loose stools today, feeling a bit tired, noticed some itching

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