Chemotherapy Checklist Form
Complete this form to track and confirm all key steps for your chemotherapy visit preparation and day-of-treatment checklist.
Patient Name
*
First Name
Last Name
Date of Birth (Month/Year only)
*
Appointment Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Pre-Treatment Preparation Checklist
Fasted if required
Hydrated
Brought required documents
Wore comfortable clothing
Other
Current Symptoms or Concerns
Recent Medication Changes
Known Allergies
Transportation/Escort Confirmation
I have arranged transportation or an escort
I will be driving myself
Other arrangement
Day-of-Treatment Acknowledgments (check all that apply)
I have reviewed my treatment plan
I understand today’s procedure
I have no new symptoms to report
Other
Staff/Patient Signature (optional)
Submit Checklist
Submit Checklist
Should be Empty: