Oncology — Chemotherapy Follow-up Template

Visit Information

Date: [Date]
Visit type: Pre-chemotherapy / Post-chemotherapy / Treatment assessment
Days since last treatment: [X]

Patient Identification

Diagnosis: [Cancer type, stage]
Current regimen: [Name]
Cycle: [X] of [X] planned
Day: [X] of cycle
Treatment intent: Curative / Neoadjuvant / Adjuvant / Palliative

Current Status

Performance status: ECOG [0-4]

• Change from baseline: None / Improved / Declined

Weight: [X] — Change: [+/- X] lbs since last visit
BSA: [X] m² — Dose recalculation needed: Yes / No

Interval History

Overall tolerance: Good / Fair / Poor

Toxicity Assessment (CTCAE v5.0)

Hematologic:

Toxicity	Grade	Nadir	Current	Management
Neutropenia	[0-4]	[Date, ANC]	[ANC]	[G-CSF, delay]
Anemia	[0-4]	[Hgb]	[Hgb]	[Transfusion, ESA]
Thrombocytopenia	[0-4]	[Plt]	[Plt]	[Transfusion, delay]

Febrile neutropenia: No / Yes — [Date, management]
Bleeding: No / Yes — [Description]
Infections: No / Yes — [Type, treatment]

Gastrointestinal:

Toxicity	Grade	Duration	Management
Nausea	[0-3]	[Days]	[Antiemetics]
Vomiting	[0-4]	[Episodes/day]	[Antiemetics]
Diarrhea	[0-5]	[Stools/day]	[Antidiarrheals]
Constipation	[0-4]	[Days]	[Laxatives]
Mucositis	[0-4]	[Description]	[Treatment]
Anorexia	[0-3]	[Duration]	[Support]

Neurologic:

Toxicity	Grade	Description	Management
Peripheral neuropathy	[0-4]	[Sensory/motor, distribution]	[Dose modification]
Cognitive	[0-3]	[Description]	[Support]

Dermatologic:

Toxicity	Grade	Description	Management
Hand-foot syndrome	[0-3]	[Description]	[Treatment]
Rash	[0-4]	[Distribution]	[Treatment]
Alopecia	[0-2]	[Extent]	[Support]
Nail changes	[0-2]	[Description]	[Treatment]

Constitutional:

Toxicity	Grade	Description	Management
Fatigue	[0-3]	[Impact on ADLs]	[Support]
Fever	[0-3]	[Max temp]	[Evaluation]

Cardiovascular:

Toxicity	Grade	Description	Management
Hypertension	[0-4]	[BP readings]	[Medications]
Cardiac	[0-5]	[Symptoms, EF change]	[Cardiology]

Other Toxicities:

[List any additional toxicities with CTCAE grade]

Symptom Control

Pain: [0-10] — Controlled: Yes / No

• Current regimen: [Medications]
• Adjustment needed: None / [Change]

Antiemetic efficacy: Good / Fair / Poor

• Current regimen: [Medications]
• Adjustment: None / [Change]

Sleep: Normal / Insomnia — Treatment: [If applicable]
Mood: Normal / Depressed / Anxious — Referral: [If needed]

Laboratory Review

Pre-Treatment Labs ([Date])

CBC:

• WBC: [X] (ANC: [X])
• Hgb: [X]
• Plt: [X]

CMP:

• Cr: [X], GFR: [X]
• Bilirubin: [X]
• AST/ALT: [X]/[X]
• Albumin: [X]

Other: [Tumor markers, specific labs]

Lab Trends

Parameter	Baseline	Nadir	Current	Trend
ANC	[X]	[X]	[X]	[Stable/improving/declining]
Hgb	[X]	[X]	[X]	[Stable/improving/declining]
Plt	[X]	[X]	[X]	[Stable/improving/declining]

Physical Examination

Vital Signs

BP: [X/X]
HR: [X]
Temp: [X]°F
Weight: [X]
SpO2: [X]%

General

Appearance: [Well, fatigued, ill-appearing]
ECOG: [0-4]

Focused Exam

HEENT: [Mucositis assessment]
Cardiovascular: [Rhythm, edema]
Pulmonary: [Breath sounds]
Abdominal: [Hepatomegaly, ascites]
Skin: [Rash, hand-foot syndrome, port site]
Neurologic: [Neuropathy assessment]

Port/Line Assessment

Type: Port / PICC / Hickman
Site: [Clean, dry, intact / Concerns]
Function: Good / [Issues]

Response Assessment (if applicable)

Last restaging: [Date]
Imaging: [Modality, findings]
Response: CR / PR / SD / PD (RECIST criteria)
Tumor markers: [Trend]

Treatment Decision

Eligibility for Today's Treatment

Labs acceptable: Yes / No — [Issues]
Toxicities acceptable: Yes / No — [Grade limiting]
Performance status acceptable: Yes / No
Decision:
[ ] Proceed with treatment as planned
[ ] Proceed with dose modification
[ ] Hold treatment — Reason: [X]
[ ] Treatment complete
[ ] Change regimen

Dose Modifications

Prior modifications: None / [List]
Today's modifications:

Drug	Standard Dose	Today's Dose	Reason
[Name]	[Dose]	[Dose]	[Toxicity/lab]

Cumulative dose: [If tracking required — anthracyclines, etc.]

Supportive Medications

Growth factors: Not indicated / [G-CSF schedule]
Antiemetics: [Pre-medications]
Hydration: Standard / Enhanced — [Volume]
Other pre-meds: [Steroids, antihistamines, etc.]

Plan

1) [Treatment decision with specific drugs/doses]
2) [Dose modifications if any]
3) [Toxicity management]
4) [Supportive care adjustments]
5) [Labs and monitoring]

Orders

• [ ] Chemotherapy: [Regimen, doses]
• [ ] Pre-medications: [List]
• [ ] Supportive medications: [List]
• [ ] Labs: [Type, timing]
• [ ] Imaging: [If indicated]
• [ ] Growth factor: [If indicated]

Patient Education

• Treatment plan for today
• Expected side effects
• When to call/emergency instructions
• Next appointment

Follow-up

Next treatment: [Date]
Next labs: [Date]
Restaging: [Date if indicated]
Return sooner if: [Fever, severe symptoms, concerns]