Leukemia Treatment Progress Tracking Chart

Patient Self-Monitoring and Treatment Response Documentation

Oncology

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Template Content

Last updated: Mar 24, 2025

Patient Information

Name: _________________________ Date of Diagnosis: ______________ Type of Leukemia: ______________

Blood Count Tracking

Complete Blood Count (CBC)

Date WBC RBC Platelets Neutrophils Notes

Symptoms Monitor

Rate your symptoms (0-10 scale)

  • Fatigue: ___
  • Bone pain: ___
  • Night sweats: ___
  • Fever: ___
  • Bruising/bleeding: ___

Treatment Schedule

Medication Log

  • Medication name: _____________
  • Dosage: ____________________
  • Frequency: _________________
  • Side effects observed: _______

Important Contacts

  • Oncologist: ________________
  • Nurse Navigator: ___________
  • Emergency Contact: _________

Notes



Next Appointment

Date: ________________________ Time: ________________________

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