Survivorship Care Plan Builder
Fill in the PanCare Survivorship Care Plan (short version) in your browser: treatment summary, health history, follow-up recommendations and shared decisions, then print it or save it as a PDF to complete with your clinician.
This builder reproduces the PanCare Survivorship Care Plan – Short Version as an online form. It does not generate recommendations: section 2 needs your hospital records and section 4 needs a healthcare provider who knows the follow-up guidelines. Fill in what you know, print it, and complete the rest together at your follow-up visit.
Talk to your oncology team, GP or a registered dietitian before acting on any number here. They know your history; a calculator does not.
Your survivorship care plan
Type the entries you know and leave the rest blank for your clinic. Everything stays on this device until you print it.
Read the PanCare Survivorship Care Plan explained section by section
Your completed plan
This is what prints. Blank fields print as blank lines for the clinic to complete.
PanCare Survivorship Care Plan – Short Version
Date of completion: …… · Completed by: ……
1a. General information
This part describes your basic information.
- (Preferred) name
- Date of birth
- Sex at birth
- Gender identity
- Telephone number
- E-mail address
- Names of parents / caregivers (if applicable)
- Emergency contact person
- Telephone number of emergency contact person
- Treatment centre
- Treating oncologist
- General practitioner
- Allergies
1b. Current medications
This part lists all medications that are currently needed.
2. Treatment summary
This part describes your diagnoses and all treatments you received. Your treating hospital holds these details; ask for them if you do not know them.
- Primary cancer diagnosis
- Date of primary diagnosis
- Progression
- Date of progression
- Relapse
- Date of relapse
- Metastases
- Secondary malignancy
- Type of secondary malignancy
- Date of diagnosis of secondary malignancy
- Chemotherapy
- Type of chemotherapy
- Total amount of anthracyclines
- Total amount of alkylating agents
- Radiotherapy
- Type of radiotherapy, total amount and field
- Stem cell transplantation
- Type of stem cell transplantation
- Date of stem cell transplantation
- Major surgery
- Type of surgery
- Date of surgery
- Immunotherapy
- Type of immunotherapy
- Other therapy
- Type of other therapy
3. History and health problems
This part describes any serious health problems (physical and mental) during and after treatment, including already diagnosed late effects.
| Date | Condition or problem | Current or past |
|---|---|---|
3a. Other medical history
This part describes other medical history that is relevant to know.
- Congenital or hereditary diseases
- Medical history in your family
- Other
4. Recommendations for follow-up
Because treatments can increase the risk of developing physical and mental health problems later in life, it is essential to report any symptoms to your doctor right away. Early reporting helps identify potential causes sooner and can prevent more serious health issues. This table is completed with your healthcare provider.
| Because you were treated with… | …you may have a risk of… | …therefore, we advise that you get the following care: | The decision that you together with your healthcare provider have made about your care | Remarks, deviations and contact persons for care |
|---|---|---|---|---|
4a. Decisions about your care that are personally important for you
4b. Direct links to PLAIN summaries
www.pancare.eu/plain-language-summaries
5. Recommendations for general health
A healthy lifestyle improves the processes in your body that help you feel good both physically and mentally. It can reduce the risk of fatigue, depression, cardiovascular disease, new (secondary) malignancies, and other (mental) health problems.
Regarding a healthy lifestyle, it is recommended to:
- Have enough sleep
- Exercise regularly (at least 3 times a week)
- Maintain a healthy weight (adult BMI between 18.5 and 24.9 kg/m2)
- Eat plenty of fruits and vegetables; reduce your intake of fats, sugar, and salt
- Do not smoke, or quit if you currently smoke
- Limit alcohol consumption
- Protect your skin: use sunscreen and avoid excessive sunbathing
Regarding physical health, it is recommended to:
- Have your teeth checked regularly
- Monitor your health measurements, including weight and blood pressure
- Participate in any cancer screenings you may be invited to
- Receive all vaccinations as recommended in national guidelines
Regarding mental health, it is recommended to:
- Connect with others
- Make time for yourself
- Reach out to family members or close friends when you experience negative emotions
- Engage in hobbies you enjoy or explore new interests and activities
- Practise mindfulness
- Use relaxation techniques
- Seek professional help if needed
Regarding social health, it is recommended to:
- Discuss problems or questions about managing your daily life, such as problems or questions about work, school, relationships, finances, and so on, with your physician if those occur
- Feel free to share your needs with your loved ones
5a. Space for comments
Completed with the Beat Cancer EU Survivorship Care Plan Builder from the PanCare template (date of development: May 2026). This plan contains personal and health information; it is kept by the survivor and shared only with their consent.
Everything you type stays in your browser. Nothing is sent to our servers.
What this builder does, and what it does not
The builder is the PanCare Survivorship Care Plan – Short Version as a form: the same five sections, the same fields in the same order, and the same general-health recommendations, printed as a document you can hand to a doctor. It exists so that you can prepare the parts you know before a follow-up visit and arrive with a plan that only needs the clinical entries.
It does not calculate anything and it does not suggest follow-up. The risks and surveillance in section 4 come from the PanCare follow-up recommendations and from your own treatment history, and they have to be entered by a healthcare provider who has both in front of them. Nothing you type is sent to us; the plan lives in your browser until you print it, and clearing the form deletes it.
How to complete the plan with your clinician
- Fill in section 1 (general information and current medications) yourself.
- Enter whatever you know of section 2; leave the codes and cumulative doses blank if you are not sure.
- Print the plan or save it as a PDF and take it to your treating oncologist, your long-term follow-up clinic or your general practitioner.
- Ask them to complete the treatment summary from your medical records and to go through the follow-up recommendations with you, recording the decisions you make together.
- Keep the completed plan, show it to any new doctor, and ask for it to be updated after every follow-up visit or new diagnosis.
Where the treatment summary comes from
Section 2 asks for the diagnosis as an ICCC-3 or ICD-O-3 code, the cumulative doses of anthracyclines and alkylating agents, and the type, dose and field of any radiotherapy. These are the details follow-up guidelines are written for, and they are in your hospital records rather than in your memory. The treating hospital can provide them even years later; PanCare publishes a treatment summary template that clinics can use. If you were treated as a child, your parents may also hold discharge letters or a treatment passport with the same information.
Questions to ask at your follow-up visit
Bring the plan with you and ask:
- Which of my treatments carry a risk of late effects, and which checks do the guidelines advise for me?
- How often should each check happen, and who arranges it?
- Is there a PLAIN summary I can read for each recommendation?
- Who is my contact person for follow-up care if I move, change hospital or turn 18?
- Can I have a copy of my full treatment summary for my own records?
Sources and review
Written by the Beat Cancer EU editorial team using the primary sources below, which are also the formulas this tool implements. Last reviewed: September 16, 2026.
- PanCare — Survivorship Care Plan, Short Version (May 2026)
- PanCareFollowUp — Survivorship Care Plan template, Long Version
- PanCareFollowUp — Treatment summary template
- PanCare — Follow-up recommendations for the surveillance of late effects (IGHG)
- PanCare — PLAIN language summaries
- EU-CAYAS-NET — Recommendations for LTFU care (D3.4)
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