Patient Information
- Name: _______________
- Date: _______________
- Medical Record Number: _______________
Diagnosis Details
- Cancer Type: □ Colon Cancer □ Rectal Cancer
- Stage: _______________
- Date of Diagnosis: _______________
Treatment Team
- Primary Oncologist: _______________
- Surgeon: _______________
- Radiation Oncologist: _______________
- Nurse Navigator: _______________
Treatment Plan
Surgery
□ Planned □ Completed □ Not Applicable
- Type: _______________
- Scheduled Date: _______________
- Pre-operative Instructions: _______________
Chemotherapy
□ Planned □ Ongoing □ Completed □ Not Applicable
- Regimen: _______________
- Frequency: _______________
- Duration: _______________
- Start Date: _______________
Radiation Therapy
□ Planned □ Ongoing □ Completed □ Not Applicable
- Type: _______________
- Total Doses: _______________
- Schedule: _______________
Follow-up Care Schedule
Immediate Post-Treatment (0-6 months)
- Clinical visits every _____ months
- CEA blood tests every _____ months
- Imaging studies: _______________
Long-term Monitoring
- Colonoscopy Schedule: _______________
- CT Scan Schedule: _______________
- Other Tests: _______________
Support Services
□ Nutritionist
□ Social Worker
□ Physical Therapy
□ Support Group
□ Genetic Counseling
Emergency Contact Information
- During Office Hours: _______________
- After Hours: _______________
- Emergency Department: _______________
Notes and Special Instructions
Patient Resources
- Patient Portal: _______________
- Educational Materials: _______________
- Support Group Information: _______________