Oncology — New Patient Consultation Template

Consultation Information

Referring physician: [Name, specialty]
Reason for referral: [Chief complaint / diagnosis]
Date of consultation: [Date]
Urgency: Routine / Urgent

Chief Complaint

[Primary oncologic concern]
Current status: Newly diagnosed / Recurrent / Metastatic / Surveillance

Cancer Diagnosis

Primary site: [Organ/tissue]
Histology: [Type]
Grade: [Well/Moderately/Poorly differentiated, Grade 1-3]
Date of diagnosis: [Date]
Method of diagnosis: [Biopsy site, procedure]

Pathology Review

Original pathology: [Institution, date]

• Histologic type: [Specific diagnosis]
• Grade: [X]
• Margins: [If surgical specimen]
• Lymphovascular invasion: Yes / No
• Perineural invasion: Yes / No

Molecular/Genomic testing:

• ER/PR/HER2: [If breast]
• KRAS/NRAS/BRAF: [If colorectal]
• EGFR/ALK/ROS1/PD-L1: [If lung]
• MSI/MMR status: [If applicable]
• TMB: [If available]
• Other markers: [Specific to tumor type]

Second opinion pathology: Not obtained / [Institution, findings]

Staging

Clinical Stage

TNM: cT[X] N[X] M[X]
Stage group: [I, II, III, IV] [A/B/C if applicable]
AJCC Edition: 8th

Pathologic Stage (if surgery performed)

TNM: pT[X] N[X] M[X]

• Tumor size: [X] cm
• Nodes examined: [X] / Positive: [X]
• Margins: Negative / Positive [Location]

Staging Workup

Imaging:

• CT chest/abdomen/pelvis: [Date, findings]
• PET/CT: [Date, SUV max, findings]
• MRI: [Date, findings]
• Bone scan: [Date, findings]

Laboratory:

• Tumor markers: [CEA, CA 19-9, PSA, AFP, etc.]
• LDH: [If applicable]
• Other: [Specific markers]

Sites of metastasis: None / [List sites]

Performance Status

ECOG: [0-4]

• 0: Fully active
• 1: Restricted strenuous activity
• 2: Ambulatory, capable of self-care
• 3: Limited self-care, >50% of waking hours in bed/chair
• 4: Completely disabled

Karnofsky: [0-100]%
Changes from baseline: None / [Description]

History of Present Illness

[Narrative of cancer presentation and course]
Presenting symptoms: [List]
Duration of symptoms: [X] weeks/months
Constitutional symptoms:

• Weight loss: No / Yes — [X] lbs over [X] time ([X]% body weight)
• Fatigue: None / Mild / Moderate / Severe
• Night sweats: Yes / No
• Fever: Yes / No
• Anorexia: Yes / No

Current symptoms:

• Pain: No / Yes — Location: [X], Severity: [X]/10
• Dyspnea: No / Yes — [Severity]
• Nausea/vomiting: No / Yes
• Bowel changes: No / Yes — [Description]
• Neurologic: No / Yes — [Description]
• Other: [Symptoms]

Prior Cancer Treatment

Surgery

Procedure: None / [Procedure, date, surgeon]
Findings: [Operative findings]
Complications: None / [List]

Radiation Therapy

Treatment: None / [Site, dose, fractions, dates]
Institution: [Where treated]
Toxicities: None / [List]

Systemic Therapy

Prior regimens:

Regimen	Dates	Cycles	Best Response	Reason Stopped
[Name]	[Dates]	[X]	[CR/PR/SD/PD]	[Reason]

Toxicities from prior treatment:

• [Grade, type, resolution]

Clinical Trials

Prior participation: None / [Trial name, dates]

Cancer-Specific History

Family cancer history:

• First-degree relatives with cancer: None / [Type, age at diagnosis]
• Hereditary syndrome suspected: No / Yes — [Syndrome]
• Genetic testing: Not done / [Results]

Risk factors:

• Tobacco: [Pack-years, current status]
• Alcohol: [History]
• Occupational exposures: [List]
• Prior radiation: [If applicable]
• Viral: [HPV, HBV, HCV, HIV status if relevant]

Past Medical History

[Relevant comorbidities affecting treatment]
Cardiac:

• CAD: No / Yes — [Details]
• CHF: No / Yes — EF: [X]%
• Arrhythmia: No / Yes — [Type]

Pulmonary:

• COPD: No / Yes — [Severity]
• ILD: No / Yes

Renal:

• CKD: No / Yes — Stage: [X], GFR: [X]

Hepatic:

• Liver disease: No / Yes — [Type, Child-Pugh]

Neurologic:

• Neuropathy: No / Yes — [Baseline grade]

Autoimmune:

• [Conditions relevant to immunotherapy]

Diabetes: No / Yes — [Type, control]
Thromboembolic: No / Yes — [History, anticoagulation]

Surgical History

[Relevant surgeries]

Medications

Current medications: [List with doses]
Anticoagulation: None / [Drug, indication]
Immunosuppressants: None / [Drug, indication]
Supplements/herbals: [List]

Allergies

[Drug allergies with reactions]
Prior chemotherapy reactions: None / [Drug, reaction]

Social History

Tobacco: Current / Former / Never — Pack-years: [X]
Alcohol: [Quantity, frequency]
Living situation: [Home support, caregiver availability]
Employment: [Status, disability needs]
Goals of care discussion: [Patient understanding and preferences]
Advance directive: Yes / No — [Status]
Healthcare proxy: Yes / No — [Name]

Review of Systems

[Comprehensive ROS with focus on treatment-relevant symptoms]

Physical Examination

Vital Signs

BP: [X/X]
HR: [X]
RR: [X]
Temp: [X]°F
Weight: [X] — BMI: [X]
BSA: [X] m²

General

Appearance: Well-nourished / Cachectic / [Description]
Performance status: [Correlate with ECOG]
Distress: None / [Pain, dyspnea]

HEENT

Sclera: Anicteric / Icteric
Oral: Moist / [Mucositis, thrush]
Lymphadenopathy: Cervical / Supraclavicular — None / [Description]

Cardiovascular

Rhythm: Regular / [Irregular]
Murmurs: None / [Description]
JVD: Absent / Present
Edema: None / [Grade, distribution]

Pulmonary

Breath sounds: Clear / [Decreased, crackles]
Pleural effusion: Absent / Present [Side]

Abdominal

Soft / Distended
Hepatomegaly: No / Yes — [X] cm below RCM
Splenomegaly: No / Yes
Ascites: Absent / Present
Masses: None / [Description]

Lymph Nodes

Cervical: Not enlarged / [Description]
Axillary: Not enlarged / [Description]
Inguinal: Not enlarged / [Description]

Skin

Rash: None / [Description]
Jaundice: Absent / Present
Tumor-related findings: None / [Description]

Neurological

Mental status: Alert and oriented
Cranial nerves: Intact
Motor: [5/5] throughout
Sensory: Intact / [Neuropathy baseline]

Musculoskeletal

Bone tenderness: None / [Location]

Laboratory Review

CBC:

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

CMP:

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

Tumor markers: [Specific to cancer type]
Other: [Relevant labs]

Assessment

1) [Cancer diagnosis with stage]

• Histology: [Type]
• Stage: [TNM, stage group]
• Molecular profile: [Key markers]
• Performance status: ECOG [X]

2) [Treatment status]

• Newly diagnosed / Recurrent / Progressive
• Prior lines of therapy: [X]

3) [Relevant comorbidities affecting treatment]

Prognosis Discussion

Prognosis discussed: Yes / No

• Disease trajectory: [Curable, treatable, palliative intent]
• Estimated survival: [If discussed]
• Patient understanding: Good / Limited

Goals of care:

• Curative intent / Disease control / Symptom palliation
• Patient priorities: [Quality of life, longevity, specific goals]

Treatment Plan

Multidisciplinary Discussion

Tumor board: Scheduled [Date] / Discussed [Date] / Not indicated
Recommendations: [Summary]

Recommended Treatment

Intent: Curative / Neoadjuvant / Adjuvant / Palliative
Systemic therapy:

• Regimen: [Name]
• Drugs: [List with doses]
• Schedule: [Cycle length, number of planned cycles]
• Start date: [Date]

Radiation therapy:

• [ ] Not indicated
• [ ] Recommended — [Site, referral to radiation oncology]

Surgery:

• [ ] Completed
• [ ] Planned — [Procedure, date]
• [ ] Not indicated

Clinical trial:

• [ ] Eligible — [Trial name]
• [ ] Not eligible — [Reason]
• [ ] Discussed, patient declined

Pre-Treatment Requirements

• [ ] Port placement
• [ ] Baseline echocardiogram (EF: [X]%)
• [ ] PFTs
• [ ] Fertility preservation counseling
• [ ] Dental clearance
• [ ] Hepatitis B screening
• [ ] Other: [Specific requirements]

Supportive Care

Antiemetics: [Regimen]
Growth factor support: Not planned / [G-CSF indication]
Bone-modifying agents: Not indicated / [Zoledronic acid, denosumab]
Pain management: [Current regimen]
Nutrition: [Assessment, supplements]
Psychosocial: [Social work, psychology referral]

Monitoring Plan

Labs: [Frequency, specific tests]
Imaging: [Restaging schedule]
Tumor markers: [Frequency]
Response assessment: After [X] cycles

Patient Education

• Diagnosis and stage explained
• Treatment plan and goals discussed
• Expected side effects reviewed
• Emergency contact information provided
• Importance of reporting symptoms
• Fertility implications (if applicable)

Follow-up

Return: [Date] for [Treatment, labs, imaging review]

• Prior to each cycle for labs and assessment
• Restaging after [X] cycles

Contact: [Nurse navigator, on-call information]

Communication

Discussed with patient/family: [Topics, understanding confirmed]
Report sent to: [Referring physician, PCP]
Tumor board presentation: [Date if applicable]