A survivorship care plan is a written record of your cancer history, treatments received, and follow-up plan. It is your roadmap after treatment ends. Ask your cancer team to help you complete it, and share it with your primary care doctor.

Part 1: My Cancer Summary

Item	Details
Full name
Date of birth
Date of diagnosis
Type of cancer	Prostate adenocarcinoma / Other: _____________
Gleason score / Grade Group
Clinical stage (at diagnosis)	T N M___
Pathologic stage (if surgery)	T N M___
PSA at diagnosis
PSA nadir (lowest after treatment)
Most recent PSA
Genomic test results	Test: __________ Score: __________
Genetic / hereditary testing	□ Done — Result: _____________ □ Not done
BRCA or other mutation	□ Yes — Which: _____________ □ No □ Unknown

Part 2: Treatments I Received

Surgery:

Item	Details
Type of surgery	□ Robotic □ Open □ Laparoscopic
Date of surgery
Surgeon name
Hospital
Nerve sparing?	□ Bilateral □ Unilateral □ No
Lymph node dissection?	□ Yes — Number removed: Positive: □ No
Surgical margins	□ Negative □ Positive — Location: _____________
Pathologic stage
Post-op complications

Radiation Therapy:

Item	Details
Type of radiation	□ EBRT (IMRT) □ SBRT □ LDR brachy □ HDR brachy □ Combination □ Proton
Dates	Start: __________ End: __________
Number of treatments
Dose	____ Gy in ____ fractions
Areas treated	□ Prostate □ Seminal vesicles □ Pelvic lymph nodes □ Prostate bed (salvage) □ Other: _______
Radiation oncologist
Facility
Rectal spacer used?	□ Yes □ No
Fiducial markers placed?	□ Yes □ No
Side effects during treatment

Hormone Therapy (ADT):

Item	Details
Drug(s)
Type	□ LHRH agonist □ LHRH antagonist □ Oral antiandrogen □ Combined □ Other
Start date
Planned duration
End date (actual or expected)
Side effects experienced
DEXA scan done?	□ Yes — Date: ____ Result: ____ □ No
Cardiovascular monitoring?	□ Yes □ No

Chemotherapy:

Item	Details
Drug(s)
Number of cycles completed
Dates	Start: __________ End: __________
Medical oncologist
Side effects experienced

Other Treatments:

Item	Details
Focal therapy	□ Yes — Type: __________ Date: __________
Immunotherapy	□ Yes — Drug: __________ Dates: __________
Radiopharmaceutical	□ Yes — Drug: __________ Dates: __________
Clinical trial	□ Yes — Trial name/number: _____________
Other

Part 3: My Follow-Up Plan

Test / Visit	How Often	Next Due	Doctor Responsible
PSA blood test	Every ______ months
Physical exam / DRE	Every ______ months
Imaging (type: ______)	Every ___ months
DEXA scan (if on/after ADT)	Every ______ months
Testosterone level check	Every ______ months
Blood sugar / HbA1c	Every ______ months
Lipid panel (cholesterol)	Every ______ months
Cardiovascular check	Every ______ months
Dental exam	Every ______ months
Other cancer screenings
Primary care annual visit	Yearly

Part 4: What to Watch For

Signs that need prompt medical attention:

Rising PSA (your doctor will define what level is concerning for you)
New bone pain (back, hips, ribs)
New urinary problems (blood, inability to urinate, worsening leakage)
New bowel problems (rectal bleeding, persistent changes)
Leg swelling (one or both legs)
Unexplained weight loss
New weakness or numbness in legs
Fatigue that is worsening rather than improving

My specific warning signs to watch for (ask your doctor to fill in):

_____________________________________________
_____________________________________________
_____________________________________________

Part 5: My Wellness Plan

Area	My Plan
Exercise	Type: __________ Frequency: __________
Diet
Weight goal	Current: ____ Goal: ____
Smoking	□ Never □ Former □ Current — Quit plan: _____________
Alcohol
Supplements
Mental health support	□ Counselor □ Support group □ Other: _____________
Pelvic floor exercises	□ Yes — Frequency: _____________
Sexual health plan

Part 6: My Care Team

Role	Name	Phone	Fax / Portal
Primary care physician
Urologist
Radiation oncologist
Medical oncologist
Nurse navigator
Pharmacist
Physical therapist
Psychologist / counselor
Dietitian
Other