Cancer Therapy Treatment Summary
Name: Date of Birth:
Cancer diagnosis/ type:
Date of diagnosis: Diagnosis given by:
Cancer therapies
Type of surgery:
Date of surgery: Surgery performed by:
Performed at:
Pathology Findings
Tumor type:
Staging: T N M Stage:
Relevant pathology findings:
Lymph node status:
Initial work-up abnormalities:
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Medical Therapy Administered by:
Dose & Route
Dates given / any
dose reduction
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Notes about medical treatment
Was the treatment planned changed, if so, why?
List any major side effects of medical therapy
Radiation Therapy
Radiation therapy plan
Type of radiation therapy:
Area in treatment field:
Total planned dose:
Total number of planned fractions (sessions):
Date radiation therapy started: Date completed:
Total dose received:
Any notable side effects:
Oncology Team Contacts
Provider: Phone:
Provider: Phone:
Provider: Phone:
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Other therapy received:
Notes about treatment:
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