Patient Information

First Name
Last Name
My doctor is
She/he can be reached by telephone
My pharmacist is
She/he can be reached by telephone
Diagnosis
Pathology
Lymph Node Involvement
Staging
Weight kg
Height

Survivorship Care Plan:

Date of diagnosis Day Month Year
Chemotherapy regimen number of planned number given full dose discontinued due to
Acute toxicity on treatment
Change of chemotherapy due to disease progression
Strategy for response 
Need for hospitalization
Complication
Febrile neutropenia
Expected late effects from treatment
Radiation  Hospital
PMH
SBH
Others
Starting date Day Month Year
Date of completion Day Month Year

Psychosocial needs
Supportive needs
Identification of providers to coordinate aspects of continuing care
Surveillance  for recurrence and new cancers
Specific recommendations for health behaviors
Genetic testing and screening (only if indicated)