Reintegration After Cancer Treatment

Bone SarcomaTreatment Summary and Long Term Follow Up Plan

CONTACTS:

NAME: / ROLE: / TELEPHONE NO.: / EMAIL:
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text. /
NAME: / HOSPITAL NO:
DATE OF BIRTH: / Click here to enter a date. / CHI NUMBER:
AGE AT 1ST PROJECT CONTACT / DATE OF 1ST PROJECT CONTACT / Click here to enter a date. /
ETHNICITY / Choose an item. /
ADDRESS:
TELEPHONE Nos: / MOBILE: / HOME:
EMAIL:
ONCOLOGY CONSULTANT: / Choose an item. / NURSE SPECIALIST: / Click here to enter text. /
SURGICAL CONSULTANT: / Choose an item. /
GP NAME AND ADDRESS / GP TELEPHONE No:
GP Alerts and Recommendations
DIAGNOSIS: / Choose an item. / ANATOMICAL SITE: / Choose an item. /
DATE OF DIAGNOSIS: / Click here to enter a date. / LATERALITY: / Choose an item. /
TNM STAGE: / Click here to enter text. / Additional Location Information / Click here to enter text. /
TREATMENT PROTOCOL/ CLINICAL TRIAL:
TREATMENT START DATE: / Click here to enter a date. /
TREATMENT END DATE: / Click here to enter a date.

CHEMOTHERAPY:Choose an item.

REGIMES:

DATE
(Day 1 Cycle 1): / Regime / Number of Cycles
Click here to enter a date. / Choose an item. / Click here to enter text. /
Click here to enter a date. / Choose an item. / Click here to enter text. /
Click here to enter a date. / Choose an item. / Click here to enter text. /
Click here to enter a date. / Choose an item. / Click here to enter text. /

DRUGS:

DATE
(Day 1 Cycle 1): / DRUGS: / DOSE/m2: / TOTAL CUMULATIVE
Click here to enter a date. / Choose an item. / Click here to enter text. / Click here to enter text.
Click here to enter a date. / Choose an item. / Click here to enter text. / Click here to enter text.
Click here to enter a date. / Choose an item. / Click here to enter text. / Click here to enter text.
Click here to enter a date. / Choose an item. / Click here to enter text. / Click here to enter text.
Click here to enter a date. / Choose an item. / Click here to enter text. / Click here to enter text.

RADIOTHERAPY:Choose an item.

DATE: / SITE: / FRACTIONS: / TOTAL DOSE:
Click here to enter a date. /

ORGANS AT RISK FROM XRT:Choose an item.

DATE: / SITE: / TOTAL DOSE: / NOTES:
Click here to enter a date. /

SURGERY: Choose an item.

DATE: / PROCEDURE: / COMMENTS:
Click here to enter a date. / Choose an item. / Click here to enter text. /
Click here to enter text. / Click here to enter text. /

OTHER TREATMENTS: Choose an item.

DATE: / DETAILS: / COMMENTS:
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SIGNIFICANT ACUTE COMPLICATIONS DURING TREAMENT:

DATE: / COMPLICATION: / TREATMENT: / ONGOING:
Click here to enter a date. / Choose an item. /

ACTIVE PROBLEMS ON COMPLETION OF TREATMENT: Choose an item.

DATE: / COMPLICATION: / TREATMENT: / CTC GRADE:
Click here to enter a date. / Click here to enter text. / Click here to enter text. / Choose an item. /

MEDICATION AT END OF TREATMENT: Choose an item.

DATE: / NAME: / INDICATION: / DOSE & FREQUENCY: / ROUTE:
Click here to enter a date. / Click here to enter text. / Click here to enter text. / Click here to enter text. / Choose an item. /

END OT TREATMENT PHYSIOLOGICAL ASSESSMENT:

DATE: / INVESTIGATION: / RESULT: / COMMENT:
Click here to enter a date. / Height (cm) / Click here to enter text. / Click here to enter text. /
Click here to enter a date. / Weight (Kg) / Click here to enter text. / Click here to enter text. /
Click here to enter a date. / BMI / Click here to enter text. / Click here to enter text. /
Click here to enter a date. / BP (mmHg) / Click here to enter text. / Click here to enter text. /
Patient Consent:
IClick here to enter text. give ReACT Project Team consent to store and distribute my treatment summary as appropriate.
Signature: / Date: Click here to enter a date.
Checked by:
Choose an item. / Designation:
Signature: / Date: Click here to enter a date.
Completed by:
Name: / Designation:
Signature: / Date: Click here to enter a date.

Long Term Follow Up Care Plan

Please see SSN MCN Bone follow up guidelines from

Reason for deviation from above follow up guidelines:Click here to enter text.

Investigations

TESTS: / FREQUENCY: / DATES:

Re-immunisations:Choose an item.

Vaccine: / Date:
Flu vaccine can be safely given after:

Home/Family circumstances (Current Living Situation)

Current Living Situation / Date:Click here to enter a date.
Choose an item. /
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Education and Employment (Economic Activity)

Economic Activity / Date:Click here to enter a date.
ECOG Score:Choose an item. / Choose an item. /
Full/Part Time / Type(s)
Education and/or Employment at Diagnosis
Education and/or Employment at End of treatment
Future Education and/or Employment Plans at End of treatment
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Psychological

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Social

  • Activities………………………………………………………………………………
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  • Relationships………………………………………………………………………….
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  • Drugs/alcohol/smoking………………………………………………………………..
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Body image

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SEX AND FERTILITY

Fertility Discussed: Choose an item.
Risk of infertility: Low Medium High
Fertility preservation: Choose an item.
Fertility preservation details: Click here to enter text.
Date of storage: Click here to enter a date.
Location: Choose an item.
Contraception:
Discussed: Choose an item.
Date of discussion: Click here to enter a date.
Comment: Click here to enter text.

Healthy lifestyle

HEALTH CHECKS / FREQUENCY
Eye tests
Dental review
Self examination
INFORMATION AND ADVICE
Smoking
Diet
Drugs/Alcohol
Exercise
Skin Care
Insurance

Disease and treatment specific generalised information:

HNA Completed: Yes No / HNA Completion Date:
Long Term Follow Up Checked by:
Choose an item.: / Designation:
Signature: / Date: Click here to enter a date.
Long Term Follow Up Completed by:
Name: / Designation:
Signature: / Date: Click here to enter a date.

Document Distribution:

To: / Comments: / Date: / Signature/Initials:
Patient / Click here to enter a date. /
Family/Carer / Click here to enter a date. /
GP / Click here to enter a date. /
BWSOCC notes / Click here to enter a date. /
Referring Hospital(s) Notes / Click here to enter a date. /
Clinical Portal / Click here to enter a date. /
Others / Click here to enter a date. /

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