Patient Information

First Name Last Name
My family doctor is telephone
oncologist is            telephone
My pharmacist is    telephone
Diagnosis
Pathology
Lymph Node Involvement Staging
Weight kg               Height cm

BMI
weight(kg)/height^2(m^2) or 703* weight(lb)/height^2(in^2)

Treatment Plan

A. Chemotherapy

Adjuvant Advanced

Name of the regimen(by code)
Name of the component drugs in the regimen

My treatment is given every cycles
Start dates
Any drugs discontinued
Date of completion of Adjuvant treatment Day Month Year

B. Hormone Therapy

Name of the component drugs
Starting date Day Month Year
Date of completion Day Month Year

C. Radiation Therapy

Hospital PMH SBH Others
Starting date Day Month Year
Date of completion Day Month Year