Reintegration After Cancer Treatment (ReACT) Skin Cancer/Melanoma Treatment Summary and Long Term Follow Up Plan

CONTACTS: NAME: ROLE: TELEPHONE NO.: EMAIL:

NAME: Click here to enter text. HOSPITAL NO: Click here to enter text DATE OF BIRTH: Click here to enter a CHI NUMBER: Click here to date. enter text AGE AT 1ST PROJECT DATE OF 1ST Click here to CONTACT PROJECT CONTACT enter a date. ETHNICITY Choose an item. ADDRESS: Click here to enter text. TELEPHONE Nos: MOBILE Click here to enter HOME Click here to enter text. text. EMAIL: CONSULTANT: Choose an item. NURSE Click here to enter (Surgeon/Dermatologist SPECIALIST: text. ) CONSULTANT: Choose an item. CONSULTANT: Choose an item. (Surgeon) (Oncologist)

GP NAME AND ADDRESS GP TELEPHONE No: Click here to enter text. Click here to enter text.

GP Alerts and Recommendations

DIAGNOSIS: Choose an BRESLOW item. THICKNESS (MM): DATE OF DIAGNOSIS: Click here to enter AJCC STAGE: Choose an item. a date. PRIMARY SITE: Choose an item.

TREATMENT PROTOCOL/ CLINICAL TRIAL: Click here to enter text. TREATMENT START DATE: Click here to enter a date. TREATMENT END DATE: Click here to enter a date.

Page 1 of 6 FIRST LINE SYSTEMIC THERAPY:Choose an item.

REGIME: DATE REGIME NUMBER OF CYCLES (DAY 1 CYCLE 1): Click here to enter a date. Choose an item. Click here to enter text.

SECOND LINE SYSTEMIC THERAPY:Choose an item.

DATE REGIME NUMBER OF CYCLES (DAY 1 CYCLE 1): Click here to enter a date. Choose an item. Click here to enter text.

RADIOTHERAPY:Choose an item. DATE: SITE: FRACTIONS: TOTAL DOSE: Click here to enter a date.

ORGANS AT RISK FROM XRT:Choose an item. DATE: SITE: NOTES: Click here to enter a date.

SURGERY: Choose an item. DATE: PROCEDURE: COMMENTS: Click here to Choose an item. enter a date.

OTHER TREATMENTS: Choose an item. DATE: DETAILS: COMMENTS: Click here to enter a date.

SIGNIFICANT ACUTE COMPLICATIONS DURING TREAMENT:Choose an item. DATE: COMPLICATION: TREATMENT: ONGOING: Click here Choose an to enter a item. date. ACTIVE PROBLEMS ON COMPLETION OF TREATMENT: Choose an item. DATE: COMPLICATION: TREATMENT: CTC GRADE: Click here Choose an to enter a item. date.

MEDICATION AT END OF TREATMENT: Choose an item. DATE: NAME: INDICATION: DOSE & ROUTE: FREQUENCY: Click here to enter a Click Click here to Click here to Choose an date. here to enter text. enter text. item. enter text.

END OT TREATMENT PHYSIOLOGICAL ASSESSMENT: DATE: INVESTIGATION: RESULT: COMMENT: Click here to enter a Height (cm) Click here to date. enter text. Click here to enter a Weight (Kg) Click here to date. enter text. Click here to enter a BMI Click here to date. enter text. Click here to enter a BP (mmHg) Click here to date. enter text.

Patient Consent: I Click here to enter text. give ReACT Project Team consent to store and distribute my treatment summary as appropriate. Signature: Date: Click here to enter a date. Checked by: Choose an item. Designation: Signature: Date: Click here to enter a date. Completed by: Name: Designation: Signature: Date: Click here to enter a date.

Page 3 of 6 Long Term Follow Up Care Plan

Please also see WOSCAN MCN Skin Cancer follow up guidelines http://www.intranet.woscan.scot.nhs.uk/guidelines-and-protocols/skin-cancer/

Reason for deviation from above follow up guidelines:Click here to enter text.

Investigations TESTS: FREQUENCY: DATES:

Re-immunisations:Choose an item. Vaccine: Date:

Flu vaccine can be safely given after:

Home/Family circumstances (Current Living Situation) Current Living Situation Date:Click here to enter a date. Choose an item.

………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………

Education and Employment (Economic Activity) Economic Activity Date:Click here to enter a date. ECOG Score: Choose an item. Choose an item.

Full/Part Time Type(s) Education and/or Employment at Diagnosis Education and/or Employment at End of treatment Future Education and/or Employment Plans at End of treatment ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… Psychological ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………

Social

 Activities……………………………………………………………………………… …………………………………………………………………………………………….  Relationships…………………………………………………………………………. …………………………………………………………………………………………….  Drugs/alcohol/smoking……………………………………………………………….. …………………………………………………………………………………………….

Body image

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SEX AND FERTILITY Fertility Discussed: Choose an item. Risk of infertility: Low Medium High Fertility preservation: Choose an item. Fertility preservation details: Click here to enter text. Date of storage: Click here to enter a date. Location: Choose an item.

Contraception: Discussed: Choose an item. Date of discussion: Click here to enter a date. Comment: Click here to enter text.

Healthy lifestyle HEALTH CHECKS FREQUENCY Eye tests Dental review Self examination

INFORMATION AND ADVICE Smoking Diet Drugs/Alcohol Exercise Skin Care Insurance

Disease and treatment specific generalised information: Page 5 of 6 HNA Completed: Yes No HNA Completion Date: Long Term Follow Up Checked by: Choose an item.: Designation: Signature: Date: Click here to enter a date. Long Term Follow Up Completed by: Name: Designation: Signature: Date: Click here to enter a date.

Document Distribution: To: Comments: Date: Signature/Initials: Patient Click here to enter a date. Family/Carer Click here to enter a date. GP Click here to enter a date. BWSOCC notes Click here to enter a date. Referring Click here to enter a Hospital(s) Notes date. Clinical Portal Click here to enter a date. Others Click here to enter a date.