Q13: Acute effects: (before 6 months) 1 = yes 2 = no |___|

Grade

Q14: If so, which ones?

Q14A: Acute radiation cystitis 1 = yes 2 = no |___|

Q14B: Acute Radiodermatitis 1 = yes 2 = no |___|

Q14C: Mucosal dryness 1 = yes 2 = no |___|

Q14D: Acute rectitis/proctitis 1 = yes 2 = no |___|

Q14E: Loss of pubic hair 1 = yes 2 = no |___|

Q 14F: Hemorrhoid 1 = yes 2 = no |___|

Q14G: Enteritis 1 = yes 2 = no |___|

Q14H: Others________________________________________

Q15: Late effects (after 6 months) 1 = yes 2 = no |___|

Q16: If so, which ones?

Q16A: Pelvic fibrosis 1 = yes 2 = no |___|

Q16B: vaginal stenosis 1 = yes 2 = no |___|

Q16C: dryness of the mucosa 1 = yes 2 = no |___|

Q16D: Synechiae 1 = yes 2 = no |___|

Q16E: Pruritus 1 = yes 2 = no |___|

Q16F: Fistulas 1 = yes 2 = no |___|

Q16F1: If yes

1 = rectoovaginal 2 = vesicovaginal |___| 3 = recto-vesico vaginal

Q16G: Chronic Radiation Rectitis 1 = yes 2 = no |___|

Q16H: Chronic radiodermatitis 1 = yes 2 = no |___|

Q16I: Chronic Radiation Cystitis 1 = yes 2 = no |___|

Q16J: Affection of the phaneras 1 = yes 2 = no |___|