A complete picture of each cancer patient — diagnosis, treatment history, symptoms, and goals.
Healthcare template · 15 fields (5 required) · ~3 min for respondents to complete · Free plan · No credit card · Fully customizable
About this form
Oncology intake carries more clinical weight than almost any other specialty: the assessment must capture the diagnosis and its timeline, every current treatment, side effects, symptom severity, performance status, and — increasingly central to care planning — the patient’s own goals and quality-of-life concerns. This form structures all of it into a single assessment.
The template pairs standardized ratings (symptom severity, performance status) with open narrative fields (pain assessment, goals and concerns), because oncology care needs both: comparable scores for the tumor board, and the patient’s own words for the care conversation.
Best practices
Send the form ahead of the visit when possible — patients give more complete treatment histories at home with their records in reach than in an exam room.
Performance status drives eligibility discussions; make sure staff completing the form on a patient’s behalf use the scale definitions consistently.
Do not skip the emotional-concerns and goals fields under time pressure. They routinely surface the issues that change care plans.
Review side-effect checkboxes against the current-treatment list at every visit — mismatches are how manageable toxicities become dose reductions.
Every field, explained
Patient Name (Name, required)
Date of Birth (Date, required)
Cancer Diagnosis (Long text, required)
Date of Initial Diagnosis (Date)
Oncologist/Cancer Specialist (Short text)
Current/Recent Treatments (Multiple choice) — Checkboxes covering the modalities in play — chemotherapy, radiation, immunotherapy, surgery, hormonal.
Treatment Timeline (Long text)
Treatment Side Effects (Multiple choice)
Overall Symptom Severity (Single choice, required) — A standardized rating that makes symptom burden trackable across visits.
Performance Status (Single choice, required) — The standardized functional score used across treatment decisions and trial eligibility.
Goals and Concerns (Long text) — The patient’s priorities in their own words. Increasingly the anchor of oncology care planning.
Frequently asked questions
What is the format of an oncology patient assessment?
A comprehensive oncology assessment covers diagnosis and date, treating oncologist, current treatments, side effects, symptom severity, performance status, pain, supportive care needs, emotional concerns, and the patient’s goals. This template follows that structure with a mix of standardized ratings and narrative fields.
Is this oncology form HIPAA compliant?
The template is HIPAA-ready: on a HIPAA-enabled plan, submissions are encrypted, access-controlled, audit-logged, and covered by a Business Associate Agreement — required for collecting protected health information like a cancer diagnosis.
Can patients complete this assessment before their appointment?
Yes, and it is often better: patients answer treatment-history questions more accurately at home. Share the secure link ahead of the visit and review the answers together in the room.
Related healthcare templates
Patient Intake Form — Comprehensive patient information and medical history form