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: Treatment Summary Diagnosis Cancer Type/Location/Histology Subtype: Non-Small Cell Lung Cancer Diagnosis Date (year): Stage: applicable ☐I ☐II ☐III ☐Not Treatment Completed Surgery Yes Surgery Date(s) (year): ☐ ☐No Surgical procedure/location/findings: Radiation Yes Body area treated: End Date (year): ☐ ☐No Systemic Therapy (chemotherapy, hormonal therapy, other) Yes ☐ ☐No of Agents Used End Dates (year) Carboplatin ☐ Cisplatin ☐ Gemcitabine ☐ Paclitaxel/Docetaxel ☐ Pemetrexed ☐ Vinorelbine ☐ Other ☐ Persistent symptoms or side effects at completion of treatment: No Yes (enter type(s)) : □ □ Treatment Ongoing Need for ongoing (adjuvant) treatment for cancer Yes No ☐ ☐ Additional treatment name Planned duration Possible Side effects Follow-up Care Plan Schedule of Clinical Visits Coordinating Provider When/How often Cancer Surveillance or Other Recommended Tests Coordinating Provider Test How
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: Treatment Summary Diagnosis Cancer Type/Location/Histology Subtype: Non-Small Cell Lung Cancer Diagnosis Date (year): Stage: ☐I ☐II ☐III ☐Not applicable Treatment Completed Surgery ☐ Yes ☐No Surgery Date(s) (year): Surgical procedure/location/findings: Radiation ☐ Yes ☐No Body area treated: End Date (year): Systemic Therapy (chemotherapy, hormonal therapy, other) ☐ Yes ☐No of Agents Used End Dates (year) ☐ Carboplatin ☐ Cisplatin ☐ Gemcitabine ☐ Paclitaxel/Docetaxel ☐ Pemetrexed ☐ Vinorelbine ☐ Other Persistent symptoms or side effects at completion of treatment: □ No □ Yes (enter type(s)) : Treatment Ongoing Need for ongoing (adjuvant) treatment for cancer ☐ Yes ☐ No Additional treatment name Planned duration Possible Side effects Follow-up Care Plan Schedule of Clinical Visits Coordinating Provider When/How often Cancer Surveillance or Other Recommended Tests Coordinating Provider Test How