During the current COVID 19 pandemic the Prehab4Cancer team has moved to remote service delivery and are continuing to accept new referrals and support existing programme participants via telephone and video call appointments. Please advise patients that their service provision will be home-based using a tailored home exercise programme, sent to them either via e-mail or the post, and the instructors will still provide regular support via telephone and digital platforms.

Please use this page to refer your patient to the Prehab4Cancer programme

About you (person making the referral)

First name in full
Surname
Referring Hospital	Please select... Salford Royal Hospitals Trust Royal Bolton Hospital Royal Albert Edward Infirmary Leigh Infirmary Wrightingon Hospital Fairfield General Hospital (Bury) North Manchester General Hospital The Royal Oldham Hospital Rochdale Infirmary Manchester Royal Infirmary (Central MFT) Trafford General Hospital Wythenshawe Hospital (South MFT) Withington Community Hospital Altrincham Hospital Stepping Hill Hospital Tameside General Hospital The Christie NHS FT
Contact telephone
NHS.net Email address

About your patient (person being referred)

First name in full
Surname
Gender	MaleFemaleTransgender
Date of birth	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
1st line of address
2nd line of address
3rd line of address
Postcode
Mobile Number (either patient's or a relative's/carer's mobile number)
Email address
NHS number
Cancer Type / Site Cancer – Colorectal: Chemo/Rad prior to Surgery Cancer – Colorectal: Straight to Surgery Cancer – Lung: Chemotherapy Cancer – Lung: Radiotherapy Cancer – Lung: Straight to Surgery Cancer – Oesaphageal/Gastric: Chemo prior to Surgery Cancer – Oesaphageal/Gastric: Straight to Surgery Cancer - Pelvic – Radiotherapy
Date of cancer diagnosis	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900
Estimated date of surgery/date treatment due to commence (Chemo/Radiotherapy)	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2020 2021 2022 2023 2024 2025 2026
Treatment plan PLEASE PROVIDE A BP READING AND RESTING HEART RATE. THIS IS ESSENTIAL TO ASSESSING THE SAFETY OF HOME EXERCISE FOR PATIENTS DURING THE COVID 19 PANDEMIC Please let us know of any pre-existing health conditions and/or other concerns which may impact on a patient's ability to participate fully in this programme for example but not limited to: moderate to severe mental health symptoms, learning disabilities, sensory loss, cognitive impairment or other conditions. It is recommended for patients with such needs to attend their first assessment session with an appropriate family member or carer.
Incremental Shuttle Walk Test (ISWT) score (if applicable).
Vo2max (if applicable)
6 Minute Walk Test (6MWT) score (if applicable)
Cardiopulmonary Exercise Test (CPET)	YesNoAwaiting CPET
If patient has had CPET was the outcome satisfactory for them to proceed to Prehab (see tumour-specific patient pathways for more details)?	YesNo

Relevant Medical History

Please let us know particularly if the person being referred has any cardiac risk or other health conditions which could impact on their ability to participate in intensive exercise.

Nutritional Status

Please include any relevant information regarding patients nutritional status (e.g liquid diet, feeding tubes, IDDSI descriptor)

We recommend all patients have a Malnutrition Universal Screening Tool completed with them prior to referral. Please follow nutritional care plans as per local policy or visit www.bapen.org.uk for further information. Please provide the following:

Current Weight (kg)
Height (cm)
BMI
Weight 3-6 months ago
Weight Loss (%)
Acute disease score	YesNo
The MUST score

About the patient's GP

	I am the patient's GP
First name in full
Surname
Practice name
Contact telephone

About the patient's cancer consultant

First name
Surname

About the patient's Cancer Nurse Specialist (CNS)

First name in full
Surname
Contact telephone

Consent statement

Please tick box to indicate the patient has provided informed consent to being referred into the Prehab4Cancer programme and for their personal details to be shared between their healthcare provider and Salford Community Leisure Limited (SCL) on behalf of GM Active staff delivering the Prehab4Cancer programme. The patient understands their details will be stored in an appropriate confidential manner in accordance with SCL's Privacy Policy which is available on SCL's website.