<p> Reintegration After Cancer Treatment (ReACT) Skin Cancer/Melanoma Treatment Summary and Long Term Follow Up Plan</p><p>CONTACTS: NAME: ROLE: TELEPHONE NO.: EMAIL:</p><p>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)</p><p>GP NAME AND ADDRESS GP TELEPHONE No: Click here to enter text. Click here to enter text.</p><p>GP Alerts and Recommendations</p><p>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.</p><p>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.</p><p>Page 1 of 6 FIRST LINE SYSTEMIC THERAPY:Choose an item.</p><p>REGIME: DATE REGIME NUMBER OF CYCLES (DAY 1 CYCLE 1): Click here to enter a date. Choose an item. Click here to enter text.</p><p>SECOND LINE SYSTEMIC THERAPY:Choose an item.</p><p>DATE REGIME NUMBER OF CYCLES (DAY 1 CYCLE 1): Click here to enter a date. Choose an item. Click here to enter text.</p><p>RADIOTHERAPY:Choose an item. DATE: SITE: FRACTIONS: TOTAL DOSE: Click here to enter a date.</p><p>ORGANS AT RISK FROM XRT:Choose an item. DATE: SITE: NOTES: Click here to enter a date.</p><p>SURGERY: Choose an item. DATE: PROCEDURE: COMMENTS: Click here to Choose an item. enter a date.</p><p>OTHER TREATMENTS: Choose an item. DATE: DETAILS: COMMENTS: Click here to enter a date.</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>Page 3 of 6 Long Term Follow Up Care Plan</p><p>Please also see WOSCAN MCN Skin Cancer follow up guidelines http://www.intranet.woscan.scot.nhs.uk/guidelines-and-protocols/skin-cancer/</p><p>Reason for deviation from above follow up guidelines:Click here to enter text.</p><p>Investigations TESTS: FREQUENCY: DATES:</p><p>Re-immunisations:Choose an item. Vaccine: Date:</p><p>Flu vaccine can be safely given after:</p><p>Home/Family circumstances (Current Living Situation) Current Living Situation Date:Click here to enter a date. Choose an item.</p><p>………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………</p><p>Education and Employment (Economic Activity) Economic Activity Date:Click here to enter a date. ECOG Score: Choose an item. Choose an item.</p><p>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 ………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………</p><p>Social</p><p> Activities……………………………………………………………………………… …………………………………………………………………………………………….  Relationships…………………………………………………………………………. …………………………………………………………………………………………….  Drugs/alcohol/smoking……………………………………………………………….. …………………………………………………………………………………………….</p><p>Body image</p><p>………………………………………………………………………………………………… ………………………………………………………………………………………………… …………………………………………………………………………………………………</p><p>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.</p><p>Contraception: Discussed: Choose an item. Date of discussion: Click here to enter a date. Comment: Click here to enter text.</p><p>Healthy lifestyle HEALTH CHECKS FREQUENCY Eye tests Dental review Self examination</p><p>INFORMATION AND ADVICE Smoking Diet Drugs/Alcohol Exercise Skin Care Insurance</p><p>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.</p><p>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.</p>