An Example of a Survivor’s Follow-up Plan 1.Patient name: ____________________________________ Tel. #:_______________ Address: ________________ City, State, Zip ____________________________ 2.Hospitals where treated and Medical record numbers: _________________________ ____________________________________________________________________ ____________________________________________________________________ 3.Diagnosis (date______): Type of cancer____________________________________ Pathology and grade__________________________________________ 4.Doctors involved in care: Oncologist: _________________________________________ Address: _______________________________________ Telephone number: _______________________________ Primary Doctor: _________________________________________ Address: _______________________________________ Telephone number: _______________________________ Consultant: _________________________________________ Address: _______________________________________ Telephone number: _______________________________ Consultant: _________________________________________ Address: _______________________________________ Telephone number: _______________________________ 5.Brief History: Clinical evaluation: ________________________________________ _______________________________________________________________________ 6.CAT, MRI, X-rays: (dates)_________________________________________ ___________________________________________________________________________ Lab tests: __________________________________________ 7.Treatment: Surgery report (date______): _______________________________________ Radiation therapy: report (date______): Type: ___________________________________ Dose: _____________________________ X-ray field: ________________________ Where performed: ___________________ 8.Chemotherapy and/or immunotherapy report (date______): Protocol: __________________________ Drugs: ____________________________ Dose: _____________________________ Frequency: ________________________ Protocol: __________________________ Drugs: ____________________________ Dose: _____________________________ Frequency: ________________________ 9.Potential short- and long-term side-effects of therapy and cancer side effects: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 10. Suggested follow-up post-treatment plans for potential second malignancies or recurrence ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 11. Follow-up recommendations for the next 10 to 20 plus years: Intervals for follow-up doctor visits: _______________________________ Tests needed (a plan): __________________________________________ ____________________________________________________________ Co-morbidities (heart, lung, stroke, diabetes, osteoporosis) __________________________ __________________________________________________________________________ __________________________________________________________________________ New Symptoms of a new, secondary, or cancer recurrence: pain fatigue loss of appetite/weight loss a new lump bleeding nausea vomiting cough Resources for supportive care for: group or family support ______________________________________________ occupational therapy/physical therapy ___________________________________ home care _________________________________________________________ psychosocial support for survivors ______________________________________ physical care (pain, nutrition, fatigue, or sexual dysfunction) __________________ __________________________________________________________________ Important information for a survivor’s files: Information on insurance, employment protection and community resources Medical reports from MD, x-rays and scans, laboratory reports of vital information Genetic Counseling Copies of cancer survivorship care plan, history, laboratory results and x-rays and scans Additional information: __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________