Cervical Cancer Survivor Information Card

Name:Medical Record Number:

Stage:Lymph node status:

Histology:

Treatment: Primary surgery Primary chemoradiation Adjuvant radiation Adjuvant chemotherapy

Physicians: Gynecologic Oncologist:

Radiation Oncologist:

Medical Oncologist:

Contact numbers: Gynecology Clinic: XXX-XXX-XXXX

After hours number:XXX-XXX-XXXX

Infusion Center: XXX-XXX-XXXX Navigator: XXX-XXX-XXXX

Cervical Cancer Survivor Information Card

Name:Medical Record Number:

Stage:Lymph node status:

Histology:

Treatment: Primary surgery Primary chemoradiation Adjuvant radiation Adjuvant chemotherapy

Physicians: Gynecologic Oncologist:

Radiation Oncologist:

Medical Oncologist:

Contact numbers: Gynecology Clinic: XXX-XXX-XXXX

After hours number: XXX-XXX-XXXX

Infusion Center: XXX-XXX-XXXXNavigator: XXX-XXX-XXXX

Cervical Cancer Survivor Information Card

Name:Medical Record Number:

Stage:Lymph node status:

Histology:

Treatment: Primary surgery Primary chemoradiation

Adjuvant radiation Adjuvant chemotherapy

Physicians: Gynecologic Oncologist:

Radiation Oncologist:

Medical Oncologist:

Contact numbers: Gynecology Clinic: XXX-XXX-XXXX

After hours number: XXX-XXX-XXXX

Infusion Center: XXX-XXX-XXXXNavigator: XXX-XXX-XXXX

Cervical Cancer Survivor Information Card

Name:Medical Record Number:

Stage:Lymph node status:

Histology:

Treatment: Primary surgery Primary chemoradiation

Adjuvant radiation Adjuvant chemotherapy

Physicians: Gynecologic Oncologist:

Radiation Oncologist:

Medical Oncologist:

Contact numbers: Gynecology Clinic: XXX-XXX-XXXX

After hours number: XXX-XXX-XXXX

Infusion Center: XXX-XXX-XXXXNavigator: XXX-XXX-XXXX

Cervical Cancer Survivor Information Card

Name:Medical Record Number:

Stage:Lymph node status:

Histology:

Treatment: Primary surgery Primary chemoradiation Adjuvant radiation Adjuvant chemotherapy

Physicians: Gynecologic Oncologist:

Radiation Oncologist:

Medical Oncologist:

Contact numbers:Gynecology Clinic: XXX-XXX-XXXX

After hours number:XXX-XXX-XXXX

Infusion Center: XXX-XXX-XXXXNavigator: XXX-XXX-XXXX

Cervical Cancer Survivor Information Card

Name:Medical Record Number:

Stage:Lymph node status:

Histology:

Treatment: Primary surgery Primary chemoradiation

Adjuvant radiation Adjuvant chemotherapy

Physicians: Gynecologic Oncologist:

Radiation Oncologist:

Medical Oncologist:

Contact numbers: Gynecology Clinic: XXX-XXX-XXXX

After hours number:XXX-XXX-XXXX

Infusion Center: XXX-XXX-XXXX Navigator: XXX-XXX-XXXX

Cervical Cancer Survivor Information Card

Name:Medical Record Number:

Stage:Lymph node status:

Histology:

Treatment: Primary surgery Primary chemoradiation

Adjuvant radiation Adjuvant chemotherapy

Physicians: Gynecologic Oncologist:

Radiation Oncologist:

Medical Oncologist:

Contact numbers: Gynecology Clinic: XXX-XXX-XXXX

After hours number: XXX-XXX-XXXX

Infusion Center: XXX-XXX-XXXXNavigator: XXX-XXX-XXXX

Cervical Cancer Survivor Information Card

Name:Medical Record Number:

Stage:Lymph node status:

Histology:

Treatment: Primary surgery Primary chemoradiation

Adjuvant radiation Adjuvant chemotherapy

Physicians: Gynecologic Oncologist:

Radiation Oncologist:

Medical Oncologist:

Contact numbers: Gynecology Clinic: XXX-XXX-XXXX

After hours number: XXX-XXX-XXXX

Infusion Center: XXX-XXX-XXXXNavigator: XXX-XXX-XXXX

Cervical Cancer Survivor Information Card

Surveillance Plan: / 0-24 months / 2 years and after
Review of Symptoms / Every 6 months / Yearly
Physical Exam / Every 6 months / Yearly
Cytology (Pap smear) / Yearly / Yearly

Symptoms to report to your doctor:

Vaginal bleeding; Rectal bleeding; Blood in urine; New and persistent pain, cough, nausea or vomiting; Leg swelling;New masses (ex: bumps in your neck or groin); Any other concerns.

Cervical Cancer Survivor Information Card

Surveillance Plan: / 0-24 months / 2 years and after
Review of Symptoms / Every 6 months / Yearly
Physical Exam / Every 6 months / Yearly
Cytology (Pap smear) / Yearly / Yearly

Symptoms to report to your doctor:

Vaginal bleeding; Rectal bleeding; Blood in urine; New and persistent pain, cough, nausea or vomiting; Leg swelling; New masses (ex: bumps in your neck or groin); Any other concerns.

Cervical Cancer Survivor Information Card

Surveillance Plan: / 0-24 months / 2 years and after
Review of Symptoms / Every 6 months / Yearly
Physical Exam / Every 6 months / Yearly
Cytology (Pap smear) / Yearly / Yearly

Symptoms to report to your doctor:

Vaginal bleeding; Rectal bleeding; Blood in urine; New and persistent pain, cough, nausea or vomiting; Leg swelling; New masses (ex: bumps in your neck or groin); Any other concerns.

Cervical Cancer Survivor Information Card

Surveillance Plan: / 0-24 months / 2 years and after
Review of Symptoms / Every 6 months / Yearly
Physical Exam / Every 6 months / Yearly
Cytology (Pap smear) / Yearly / Yearly

Symptoms to report to your doctor:

Vaginal bleeding; Rectal bleeding; Blood in urine; New and persistent pain, cough, nausea or vomiting; Leg swelling; New masses (ex: bumps in your neck or groin); Any other concerns.

Cervical Cancer Survivor Information Card

Surveillance Plan: / 0-24 months / 2 years and after
Review of Symptoms / Every 6 months / Yearly
Physical Exam / Every 6 months / Yearly
Cytology (Pap smear) / Yearly / Yearly

Symptoms to report to your doctor:

Vaginal bleeding; Rectal bleeding; Blood in urine; New and persistent pain, cough, nausea or vomiting; Leg swelling; New masses (ex: bumps in your neck or groin); Any other concerns.

Cervical Cancer Survivor Information Card

Surveillance Plan: / 0-24 months / 2 years and after
Review of Symptoms / Every 6 months / Yearly
Physical Exam / Every 6 months / Yearly
Cytology (Pap smear) / Yearly / Yearly

Symptoms to report to your doctor:

Vaginal bleeding; Rectal bleeding; Blood in urine; New and persistent pain, cough, nausea or vomiting; Leg swelling; New masses (ex: bumps in your neck or groin); Any other concerns.

Cervical Cancer Survivor Information Card

Surveillance Plan: / 0-24 months / 2 years and after
Review of Symptoms / Every 6 months / Yearly
Physical Exam / Every 6 months / Yearly
Cytology (Pap smear) / Yearly / Yearly

Symptoms to report to your doctor:

Vaginal bleeding; Rectal bleeding; Blood in urine; New and persistent pain, cough, nausea or vomiting; Leg swelling; New masses (ex: bumps in your neck or groin); Any other concerns.

Cervical Cancer Survivor Information Card

Surveillance Plan: / 0-24 months / 2 years and after
Review of Symptoms / Every 6 months / Yearly
Physical Exam / Every 6 months / Yearly
Cytology (Pap smear) / Yearly / Yearly

Symptoms to report to your doctor:

Vaginal bleeding; Rectal bleeding; Blood in urine; New and persistent pain, cough, nausea or vomiting; Leg swelling; New masses (ex: bumps in your neck or groin); Any other concerns.

Cervical Cancer Low Risk Information CardSociety of Gynecologic Oncology