Oncera Health
Survivorship care plan template
A worksheet to organize your own record of life after cancer treatment.
This is an educational worksheet, not medical advice, and not a substitute for the official
survivorship care plan your care team creates. Fill it in with your care team, and always
follow their guidance. See the medical disclaimer.
Diagnosis summary
Cancer type, stage if known, date of diagnosis.
Treatment received
Surgery, chemotherapy, radiation, hormone therapy, or other treatments, with dates.
Care team contacts
Names, roles, and phone numbers for your oncologist, primary care, nurse navigator, and others.
Follow-up schedule
Upcoming visits and how often.
Recommended tests and frequency
Scans and lab work, and how often.
Signs and symptoms to report
What your care team asked you to watch for, and when to call.
Late and long-term effects to watch
Possible effects of your treatment to keep an eye on over time.
Health habits
Goals around nutrition, activity, sleep, alcohol, and nicotine.
Questions for the next visit
Anything you want to raise with your care team.