Lymphoma Care Plan

The Lymphoma Research Foundation is pleased to provide this Lymphoma Care Plan as a resource
and guide to help patients and their physicians discuss and document the cancer experience.
Keeping your information in one location can help you feel more in control during and after treatment. Patients should complete this
form with their care team. For additional copies of the Care Plan, please visit lymphoma.org/publications or contact the LRF Helpline
at (800) 500-9976 or helpline@lymphoma.org.

SECTION 1: GENERAL PATIENT INFORMATION

DATE OF BIRTH GENDER
NAME:
(MM/DD/YYYY): ❏ Male ❏ Female ❏ Prefer not to identify

PATIENT ID: PATIENT’S EMAIL:

PATIENT PHONE Primary: ( ❏ Primary ❏ Home ❏ Other: )

(Cell/Home/Other) Secondary: ( ❏ Primary ❏ Home ❏ Other: )

SUPPORT PERSON NAME: RELATIONSHIP TO PATIENT:

❏ Cell Phone:
SUPPORT CONTACT INFO: ❏ Home Phone:
❏ Email:

SECTION 2: THE CARE TEAM

NAME AFFILIATION/ INSTITUTION CONTACT INFORMATION (Phone/Email)

PRIMARY CARE PROVIDER

HEMATOLOGIST/ONCOLOGIST

RADIATION ONCOLOGIST

SURGEON

TRANSPLANT COORDINATOR

OTHER PROVIDERS:

Dermatologist

Dietitian

Endocrinologist

Fertility Specialist

Nurse/ Nurse Practitioner

OB-GYN

Physical Therapist
Psychologist/ Mental
Health Provider
Social Worker

Helpline: 800 500 9976 | helpline@lymphoma.org

SECTION 3: TREATMENT SUMMARY
3A. DIAGNOSIS
DIAGNOSIS DATE CANCER TYPE: ❏ CLL/SLL ❏ HL ❏ NHL
(MM/DD/YYYY): CANCER SUBTYPE (LIST):
STAGE/STAGING ANN ARBOR: LUGANO: OTHER:
CLASSIFICATION ❏ New ❏ Recurrent ❏ New ❏ Recurrent ❏ New ❏ Recurrent

DIAGNOSIS CONFIRMED BY: STUDY DATE (MM/DD/YY) STUDY TYPE FINDINGS

BIOPSY

BLOOD TEST

GENETIC TEST

SCAN

PATIENT PRETREATMENT Weight: Height: Blood Type:

3B. TREATMENTS
CHEMOTHERAPY/ OTHER SYSTEMIC THERAPIES ❏ Yes ❏ No

REGIMEN/AGENTS INITIATION/END DATES DOSE/ADMIN. ROUTE SCHEDULE/CYCLES DOSE REDUCTION COMMENTS

1.

2.

3.

4.

RADIATION ❏ Yes ❏ No

TYPE INITIATION/END DATES BODY AREA TREATED DOSE COMMENTS

1.

2.

STEM CELL TRANSPLANT ❏ Yes ❏ No TYPE: ❏ Allogeneic ❏ Autologous

❏ Inpatient* ❏ Outpatient Donor Relationship and Information:
*Admission Date:
*Discharge Date:

CONDITIONING TRANSPLANT
CONDITIONING TREATMENT ENGRAFTMENT/REACTIONS/COMMENTS
TREATMENT DATE DATE

Helpline: 800 500 9976 | helpline@lymphoma.org

SURGERY ❏ Yes ❏ No

PROCEDURE SURGERY DATE LOCATION FINDINGS/COMMENTS

1.

2.

OTHER TREATMENTS ❏ Yes ❏ No

PROCEDURE DATE LOCATION FINDINGS/COMMENTS

3C. TREATMENT OUTCOMES

TREATMENT PART OF A CLINICAL TRIAL ❏ Yes ❏ No STUDY NUMBER (NCT#):

TREATMENT GOAL:

RESPONSE TO TREATMENT:

SERIOUS TOXICITIES/SIDE EFFECTS DURING TREATMENT:

ONGOING TOXICITIES/SIDE EFFECTS AFTER TREATMENT:

PATIENT POSTTREATMENT Weight: Height: Blood Type:

SECTION 4. FOLLOW-UP CARE

4A. MAINTENANCE/ADJUVANT TREATMENT
TREATMENT NAME: ROUTE OF ADMINISTRATION: DOSE:

PLANNED SCHEDULE AND DURATION:

POSSIBLE SIDE EFFECTS:

RESULTS:

Helpline: 800 500 9976 | helpline@lymphoma.org

4B. POSSIBLE LATE EFFECTS AND LONG-TERM SIDE EFFECTS
LIST HERE:

4C. FOLLOW-UP VISITS

TYPE OF VISIT WHEN/HOW OFTEN PERSON TO CONTACT

HEMATOLOGIST/ONCOLOGIST

BLOOD WORK/ LAB TESTS

IMAGING (CT, PET, ETC.)

PRIMARY CARE PHYSICIAN

OTHER

4D. REVACCINATION SCHEDULE

Patients should follow the recommended revaccination schedule as directed by their physician
DATE TO DATE TO
VACCINATION VACCINATION
RECEIVE RECEIVE

 easles, mumps, and

❏M
❏ Hepatitis B (HBV)
rubella (MMR)

 aemophilus influenzae type b

❏H  etanus, diphtheria, and
❏T
(Hib) series acellular pertussis (TDaP)

❏ Influenza ❏ Varicella

❏ Meningococcal conjugate ❏ Other:

❏ Pneumococcal conjugate series ❏ Other:

❏ Polio ❏ Other:

SECTION 5. WELLNESS CONCERNS AND CANCER SCREENING AND PREVENTION

❏ Alcohol Use ❏ High Blood Pressure Control

❏ Bone Health/DEXA Scan ❏ Mammography and Pap Tests (Women only)

❏ Cholesterol Management ❏ Mental Health

❏ Colonoscopy ❏ PSA and Rectal Exam (Men only)

❏ Diabetic Screening/Management ❏ Sexual Health and Fertility

❏ Diet and Nutrition/Weight management ❏ Tobacco Use/Stopping

❏ Exercise/physical activity ❏ Other:

Helpline: 800 500 9976 | helpline@lymphoma.org

 SECTION 6. SELF-ASSESSMENT OF SYMPTOMS
Check any symptoms you experience to discuss symptom management and treatment options
with a health care provider.

❏ Abdominal pain ❏ General weakness ❏ Pain with urination

❏ Changes in appetite ❏ Hair loss ❏ Relationship problems

❏ Chest pain ❏ Hearing loss ❏ Sexual dysfunction/lack of desire

❏ Chronic diarrhea ❏ Heartburn/indigestion ❏ Shortness of breath

❏ Constipation ❏ Hot flashes/night sweats ❏ Skin changes, rashes, lumps or bumps

❏ Cough or wheezing ❏ Irregular heartbeart/ palpitations ❏ Sleep disturbances

❏ Decreased exercise ability  aundice (yellowing of skin or eyes)

❏J ❏ Slurred speech

❏ Dental problems ❏ Joint pain or muscle aches ❏ Swelling of arm or leg

❏ Difficulty breathing ❏ Leg pain with exertion ❏ Swollen lymph nodes

❏ Dizziness  emory/concentration issues

❏M ❏ Urinary incontinence (leaking urine)

❏ Dry Mouth ❏ Negative body image ❏ Vision problems

 europathy (pins and needles sensation

❏N
❏ Easy bruising or bleeding ❏ Weight gain or overweight
or numbness)

❏ Fatigue  ew/changed moles or freckles

❏N ❏ Weight loss or loss of appetite

❏ Fertility concerns  umbness/weakness on one side

❏N

❏ Fever and sweats ❏ Pain or problems with eating

WOMEN ONLY

 bnormal vaginal
❏A ❏ Premature
❏ Irregular periods ❏ Vaginal discharge ❏ Painful intercourse
bleeding menopause

MEN ONLY

❏ Erectile dysfunction

LRF offers a wide range of resources that address treatment options, the latest research advances, and ways to cope
with all aspects of lymphoma and CLL/SLL, including our award-winning mobile app. LRF also provides many educational
activities, from in-person meetings to webinars for people with lymphoma, as well as fact sheets and guides, e-Updates
that provide the latest disease-specific news and treatment options. To learn more about any of these resources, visit our
website at lymphoma.org/educationresources or contact the LRF Helpline at (800) 500-9976 or helpline@lymphoma.org.

Last updated 2020