Master Copy of Forms #1

MASTER COPY OF FORMS #1

Make copies of these forms and insert them into your Wellness Book as needed

Click here to view and Print these forms using Adobe Acrobat.

My Brain Tumor Fact Sheet

Diagnosing Doctor: ________________________________________

Presenting symptoms: _______________________________________

Tumor Type: ______________________________________________

Tumor Grade: ___________________ Size: ________________

Location of Tumor: _________________________________________

Treatment Plan: ____________________________________________

__________________________________________________________

Notes: ____________________________________________________

__________________________________________________________

My Recovery Team

MEMBER	NAME	ADDRESS	PHONE
Family Doctor
Neurosurgeon
Neuro-radiologist
Neuro-oncologist
Neuro-psychologist
Physical Therapist
Occupational Therapist
Nutritionist
Imaging Center
Pharmacy
Insurance Company

My MRI/CT/PET/SPECT Results

Date of Scan ___________. Taken at ______________________

Doctor’s Explanation of Results:__________________________

__________________________________________________________

Date of Scan ___________. Taken at ______________________

Doctor’s Explanation of Results: __________________________

__________________________________________________________

My Questions for Healthcare Professionals

Question for _____________._____________________________

__________________________________________________________

Answer: ______________________________________________

__________________________________________________________

Question for _____________. ____________________________

__________________________________________________________

Answer: ______________________________________________

__________________________________________________________

Surgical Notes

Date Surgery performed: ___/___/___

Hospital: _______________________________

Surgeon: _______________________________

Pre-Surgical Medication: ________________________________

__________________________________________________________

Post-Surgical Medication: ________________________________

__________________________________________________________

Complications, if any: ___________________________________

__________________________________________________________

Percentage of tumor removed: _____ %

Surgeon’s comments: ___________________________________

__________________________________________________________

Release Date: ___/____/____

Chemotherapy Schedule

Neuro oncologist: ______________________________________

Type of chemotherapy: __________________________________

Dosage: ______________________________________________

__________________________________________________________

Date started: ___/___/___

How administered: _____________________________________

__________________________________________________________

Length of cycle: _______________________________________

__________________________________________________________

Possible side effects: ____________________________________

__________________________________________________________

Side effects to report immediately: _________________________

__________________________________________________________

Side effects you experience: ______________________________

__________________________________________________________

Things to avoid during treatment: __________________________

__________________________________________________________

Oncologist’s comments: _________________________________

__________________________________________________________

Date completed: ___/____/____

Radiation Schedule

Date Radiation started: __/___/___

Where administered: ____________________________________

Radiation oncologist: ___________________________________

Type of radiation: ______________________________________

__________________________________________________________

Number of cycles _____

__________________________________________________________

Possible side effects: ____________________________________

__________________________________________________________

Side effects you experience: ______________________________

__________________________________________________________

Oncologist’s comments: _________________________________

__________________________________________________________

Notes: _______________________________________________

__________________________________________________________

Date completed: ___/____/____