Fillable ASCO Treatment Summary and Survivorship Care Plan (National Cancer Institute)

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ASCO Treatment Summary and Survivorship Care Plan (National Cancer Institute)

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Treatment Summary
Follow-up Care Plan
ASCO Treatment Summary and Survivorship Care Plan
General Information
Patient Name:
Patient DOB:
Patient phone:
Email:
Health Care Providers (Including Names, Institution)
Primary Care Provider:
Surgeon:
Radiation Oncologist:
Medical Oncologist:
Other Providers:
Diagnosis
Cancer Type/Location/Histology Subtype:
Diagnosis Date (year):
Stage:
☐
I
☐
II
☐
III
☐
Not applicable
Treatment
Surgery
☐
Yes
☐
No
Surgery Date(s) (year):
Surgical procedure/location/findings:
Radiation
☐
Yes
☐
No
End Date (year):
Systemic Therapy (chemotherapy, hormonal therapy, other)
☐
Yes
☐
No
Names of Agents Used
End Dates (year)
Persistent symptoms or side effects at completion of treatment: □ No □ Yes (enter type(s)) :
Familial Cancer Risk Assessment
Genetic/hereditary risk factor(s) or predisposing conditions:
Genetic counseling: □ Yes □ No Genetic testing results:
Need for ongoing (adjuvant) treatment for cancer
☐
Yes
☐
No
Additional treatment name
Planned duration
Possible Side effects
Schedule of clinical visits
Coordinating Provider
When/How often
ASCO Survivorship Care Plan
Updated based on consensus conference held on 9.27.13 and the ASCO Survivorship Committee
Cancer surveillance or other recommended related tests
Coordinating Provider
What/When/How Often
Please continue to see your primary care provider for all general health care recommended for a (man) (woman) your
age, including cancer screening tests. Any symptoms should be brought to the attention of your provider:
1. Anything that represents a brand new symptom;
2. Anything that represents a persistent symptom;
3. Anything you are worried about that might be related to the cancer coming back.
Possible late- and long-term effects that someone with this type of cancer and treatment may experience:
Cancer survivors may experience issues with the areas listed below. If you have any concerns in these or other areas,
please speak with your doctors or nurses to find out how you can get help with them.
☐ Emotional and mental health ☐ Fatigue ☐ Weight changes ☐Stopping smoking
☐ Physical Functioning ☐ Insurance ☐ School/Work ☐
Financial advice or assistance
☐ Memory or concentration loss ☐ Parenting ☐ Fertility ☐ Sexual functioning
☐ Other
A number of lifestyle/behaviors can affect your ongoing health, including the risk for the cancer coming back or
developing another cancer. Discuss these recommendations with your doctor or nurse:
☐Tobacco use/cessation ☐ Diet
☐Alcohol use ☐Sun screen use
☐Weight management (loss/gain) ☐Physical activity
Resources you may be interested in:
Other comments:
Prepared by: Delivered on:
• This Survivorship Care Plan is a cancer treatment summary and follow-up plan is provided to you to keep with your
health care records and to share with your primary care provider.
• This summary is a brief record of major aspects of your cancer treatment. You can share your copy with any of your
doctors or nurses. However, this is not a detailed or comprehensive record of your care.
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ASCO Treatment Summary and Survivorship Care Plan (National Cancer Institute)

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Completed 11 June 2022

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