Cancer Follow-Up Assessment Form
Use this form to report your current recovery status, symptoms, side effects, and follow-up needs after cancer treatment.
Patient and Treatment Background
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Cancer Type / Diagnosis
*
Current Treatment Status
*
Please Select
Active treatment
Completed treatment
Maintenance
Remission
Unknown
Date of Most Recent Treatment or Visit
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Symptoms and Side Effects
Symptoms over the past 2 weeks
*
Rows
None
Mild
Moderate
Severe
Pain
1
2
3
4
Fatigue
5
6
7
8
Nausea
9
10
11
12
Vomiting
13
14
15
16
Appetite loss
17
18
19
20
Sleep problems
21
22
23
24
Shortness of breath
25
26
27
28
Fever
29
30
31
32
Swelling
33
34
35
36
Neuropathy (numbness or tingling)
37
38
39
40
Mood changes (anxiety or low mood)
41
42
43
44
New or worsening symptoms
Wellbeing and Functional Status
Wellbeing and Functional Status
*
Rows
Energy level
Ability to perform daily activities
Emotional wellbeing
Quality of life
Excellent
45
46
47
48
Good
49
50
51
52
Fair
53
54
55
56
Poor
57
58
59
60
Very poor
61
62
63
64
Overall symptom trend
*
Improving
Stable
Worsening
Follow-Up Needs and Next Steps
Medication adherence or changes since last visit
No changes
Taking as prescribed
Missed doses
Dose changed by care team
Stopped medication
Other
Questions or concerns for the care team
Preferred follow-up action
*
Schedule appointment
Receive call
Continue current plan
Urgent review
Preferred follow-up date and time
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
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