Insert Trust logo
Follow-up Care Plan
Name
Date of Birth
Consultant
Consultant
Consultant
NHS Number
Hospital Number
The above section is for demographic data and additional rows can be added if required
Contact details of Clinical team
Consultant:
_________________________________
Keyworker:
_________________________________
Telephone Number:
__________________________
Email: _______________________________________
Fax:
_______________________________________
The above section is editable for your centre.
Holistic Needs Assessment performed ____________
Date ___________
The above section is to allow documentation of a holistic needs assessment. A number of different
assessment tools are available which incorporate physical, psychological, educational, financial, social,
emotional, sexual and employment issues.
Psychosocial/school/occupation issues
The above section is potentially a very important one for some patients, especially older patients. It is
encouraged that the information here is as full as possible; this section may even require input from the unit
social worker and others if deemed appropriate. Suggested triggers include:
Education/Training – Transition/SEN
Employment – Entry to work support
Finance – On going benefits, reassessments, money management
Peer Relationships/Social – Leisure, specialist youth schemes, youth support assessment
Emotional/Mental Health – CAMHS referral, family relationships, support groups
Systems that may be Affected
Growth


Method and frequency of surveillance.
To be performed by: PTC / GP / other (delete as appropriate)
The above bullet points allow documentation of the specific long term surveillance required, the frequency
with which this will be performed and by whom. Delete this section if not required.
Growth Hormone
treatment
Height
Final height
Other growth problems
Yes / No
Start date
Finish date
Date
Date
Centile
Centile
The above section outlines potential effects on growth and allows for entry of baseline information on
growth if appropriate.
The free text section following the table is for a more detailed explanation of the late effect if required. This
section also allows for the documentation of any individual discussions with the patient which will be
pertinent and relevant to them.
Other Hormones



Method and frequency of surveillance.
To be performed by: PTC / GP / other (delete as appropriate)
The above bullet points allow documentation of the specific long term surveillance required, the
frequency with which this will be performed and by whom. Delete this section if not required .
Hormone
Recommended surveillance
The above section outlines potential effects on other hormones and allows for entry of baseline information
if appropriate.
The free text section following the table is for a more detailed explanation of the late effect if required. This
section also allows for the documentation of any individual discussions with the patient which will be
pertinent and relevant to them
Fertility


Method and frequency of surveillance.
To be performed by: PTC / GP / other (delete as appropriate)
The above bullet points allow documentation of the specific long term surveillance required, the frequency
with which this will be performed and by whom. Delete this section if not required .
Menarche
Regular periods
Yes / No
Yes / No
Delete this section for male patients
Date
Date
Semen storage
Semen analysis
result
Yes / No
Date
Date
Delete this section for female patients
Offspring
Offspring
Offspring
Date of birth
Date of birth
Date of birth
Document all offspring in this section. It may be relevant to include all pregnancy outcomes.
Referred for reproductive medicine advice _____________________ Date: _____________
Heart

Method and frequency of surveillance.
 To be performed by: PTC / GP / other (delete as appropriate)
The above bullet points allow documentation of the specific long term surveillance required, the frequency
with which this will be performed and by whom. Delete this section if not required .
End-of-treatment result
Follow-up result
Follow-up result
Specify investigation
performed (e.g. echo)
Specify investigation
performed (e.g. echo)
Specify investigation
performed (e.g. echo)
Result
Date
Result
Date
Result
Date
The above section outlines potential effects on the heart and allows for entry of baseline information on
cardiac function if appropriate.
The free text section following the table is for a more detailed explanation of the late effect if required. This
section also allows for the documentation of any individual discussions with the patient which will be
pertinent and relevant to them. It is also an ideal opportunity to address lifestyle issues such as smoking,
exercise, healthy eating, as well as the importance of cardiac follow up, regular blood pressure checks etc in
the future, and issues such as cardiac surveillance during pregnancy for female patients.
Lungs


Method and frequency of surveillance.
To be performed by: PTC / GP / other (delete as appropriate)
The above bullet points allow documentation of the specific long term surveillance required, the frequency
with which this will be performed and by whom. Delete this section if not required .
End-of-treatment result
Follow-up result
Follow-up result
Specify investigation
performed (e.g. echo)
Specify investigation
performed (e.g. echo)
Specify investigation
performed (e.g. echo)
Result
Date
Result
Date
Result
Date
The above section outlines potential effects on the lungs and allows for entry of baseline information from
respiratory function tests if appropriate.
The free text section following the table is for a more detailed explanation of the late effect if required. This
section also allows for the documentation of any individual discussions with the patient which will be
pertinent and relevant to them
Kidneys


Method and frequency of surveillance.
To be performed by: PTC / GP / other (delete as appropriate)
The above bullet points allow documentation of the specific long term surveillance required, the frequency
with which this will be performed and by whom. Delete this section if not required .
End-of-treatment GFR
Follow-up GFR
Follow-up GFR
Kidney tubular
dysfunction
Risk of high blood
pressure
BP result
Specify investigation
performed (e.g. )
Specify investigation
performed (e.g. )
Specify investigation
performed (e.g. )
Result
Date
Result
Date
Result
Date
Result
Date
mmHg
Date
Yes / No
The above section outlines potential effects on the kidney and allows for entry of baseline information on
renal function if appropriate.
The free text section following the table is for a more detailed explanation of the late effect if required. This
section also allows for the documentation of any individual discussions with the patient which will be
pertinent and relevant to them
Other Organs / Tissues
Organ at risk
Detail
Risk of Recurrence
This box is to record the discussions with the patient with respect to the risk of recurrence and the on-going
disease surveillance that will be required. If not relevant or appropriate please delete this section.
Risk of Second Malignancy
This box is to record the discussions with the patient with respect to the risk of second malignancies and the
advice given to modify those risks and any screening recommended.
Follow-up Plan Specify where, frequency, etc..
This box is to record the follow up arrangements including frequency of follow up, where it will be and with
whom. It would also be appropriate to include likely long term follow up plans including telephone
consultations, nurse-led follow up and supported self management.
Summary of Surveillance required:
Investigation
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
GENERAL
Height and weight
Pubertal status
Blood pressure
Urinanalysis
BLOOD TESTS
Full Blood Count
Urea & Electrolytes (Kidney
Function)
Liver Function Test
Lipid profile (Cholesterol etc.)
Glucose
Anterior Pituitary function tests
Gonadotrophins (Sex Hormones)
Thyroid Function
GFR (Kidney Function)
Other
OTHER
Chest X Ray
DEXA Bone Scan
Interval MRI scan
CT Scan
Echocardiogram (Heart Function)
ECG (Heart Function)
Start
Date
Frequency
___ Lung Function Tests
___ Audiometry (Hearing Test)
___ Other
The above section gives each centre a chance to summarise the surveillance required, and gives the patient an
idea of investigations that might be done. It can be amended to include areas to be asked about/explored
when the patient attends clinic.
Some investigations may only be done if there are specific problems and it is a relatively easy task to edit the
above by adding a free text field for investigations, though not routine, may be required if there are symptoms.
Follow-Up Care Plan completed by:
Signature
___________________________________________ Date ______________
Print Name / Title
_________________________________________________________
Discussed with patient _____________________________________ Date ______________