General Information Patient Name: Patient DOB: Patient Email: Health Care Providers (Including Names, Institution, Phone numbers) Primary Care Provider: Surgeon: Radiation Oncologist: Medical Oncologist: Other Providers (Navigator): Diagnosis Cancer Type/Location/Histologic type: Diagnosis Date: Tumor size: Lymph Nodes: Metastasis: Stage: available/applicable ☐I ☐II ☐III ☐IV ☐Not Other information about the cancer: Treatment Plan Treatment Goal: To cure the cancer and relieve symptoms and side effects of treatment ☐ To slow the growth of the cancer and relieve symptoms and side effects of treatment ☐ Treatment Plan Surgery Yes Surgery Date(s) (year): Procedure/location: ☐ ☐No Radiation Yes Body area to be treated: How many treatments over how many weeks: ☐ ☐No Systemic Therapy (chemotherapy, hormonal therapy, other) Yes ☐ ☐No To be given before surgery or radiation (neoadjuvant) Yes ☐ ☐No Name of regimen and agents used: Number of cycles planned and frequency: To be given after surgery or radiation (adjuvant) Yes ☐ ☐No Name of regimen and agents used: Number of cycles planned and frequency: Additional information: Symptoms or Side Effects
General Information Patient Name: Patient DOB: Patient Email: Health Care Providers (Including Names, Institution, Phone numbers) Primary Care Provider: Surgeon: Radiation Oncologist: Medical Oncologist: Other Providers (Navigator): Diagnosis Cancer Type/Location/Histologic type: Diagnosis Date: Tumor size: Lymph Nodes: Metastasis: Stage: ☐I ☐II ☐III ☐IV ☐Not available/applicable Other information about the cancer: Treatment Plan Treatment Goal: ☐ To cure the cancer and relieve symptoms and side effects of treatment ☐ To slow the growth of the cancer and relieve symptoms and side effects of treatment Treatment Plan Surgery ☐ Yes ☐No Surgery Date(s) (year): Procedure/location: Radiation ☐ Yes ☐No Body area to be treated: How many treatments over how many weeks: Systemic Therapy (chemotherapy, hormonal therapy, other) ☐ Yes ☐No To be given before surgery or radiation (neoadjuvant) ☐ Yes ☐No Name of regimen and agents used: Number of cycles planned and frequency: To be given after surgery or radiation (adjuvant) ☐ Yes ☐No Name of regimen and agents used: Number of cycles planned and frequency: Additional information: Symptoms or Side Effects
asco-treatment-plan-template.docx