Patient Information
- Name: _________________
- Date of Diagnosis: _________________
- Treating Oncologist: _________________
- Care Team Contact: _________________
Disease Status
Melanoma Classification
- Stage: ☐ I ☐ II ☐ III ☐ IV
- Location: _________________
- Genetic Status (if known): _________________
Treatment Plan
Primary Treatment
☐ Surgery
- Planned Date: _________________
- Type: _________________
- Special Instructions: _________________
☐ Immunotherapy
- Medication: _________________
- Schedule: _________________
- Duration: _________________
☐ Targeted Therapy
- Medication: _________________
- Dosing: _________________
- Duration: _________________
Follow-up Schedule
- Skin Examinations: Every _____ months
- Imaging Studies: Every _____ months
- Blood Tests: Every _____ months
Self-Care Guidelines
Sun Protection
- Use broad-spectrum SPF 30+ sunscreen daily
- Reapply every 2 hours when outdoors
- Wear protective clothing and wide-brimmed hats
- Avoid peak sun hours (10 AM - 4 PM)
Skin Monitoring
- Perform monthly self-skin examinations
- Document any changes using the ABCDE rule:
- Asymmetry
- Border irregularity
- Color variation
- Diameter >6mm
- Evolution/change
Emergency Contact Information
Call immediately if you experience:
- New or worsening symptoms
- Unexpected side effects
- Fever above 101.5°F
Emergency Contact: _________________
After Hours Number: _________________
Support Resources
- Support Group Information: _________________
- Patient Navigator: _________________
- Financial Counselor: _________________
Notes