Diagnosis Date: __/__/____
Diagnosis: _____________________________ Stage: _____________ Grade: ________________
Additional Information: __________________________________________________
Doctor’s name and contact information:
__________________________________________________
Is there anything that can be done or avoided, to prevent it from coming back?
What are the warning signs to watch for?
Are there other diseases that are likely to appear due to the original disease?
What type of follow-up testing is necessary, and how frequently?
Are there any foods, habits, activities or exercise to avoid?
What are possible long-term effects of the disease and its treatment? How can they be treated?
Do you have any suggestions regarding changes in my professional, social and personal life?