| Characteristic | Score (Circle One) | Points | Notes |
| Erythema | 0 = none 1 = mild (pink) 2 = moderate/severe (red) |
||
| Edema | 0 = none 1 = mild 2 = moderate/severe |
||
| Ulcers * | 0 = none 1 = single 2 = 2 or more ulcers |
||
| Stricture | 0 = none 1 = mild 2 = moderate/severe |
||
| Total Score: | Total Score: 0 = None 1–2 = Mild toxicity 3–4 = Moderate toxicity ≥5 = Severe toxicity |
||
| Toxicity: |
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