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
Contact telephone
NHS.net Email address
About your patient (person being referred)
First name in full  
Surname
Gender  
Date of birth
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








Date of cancer diagnosis
Estimated date of surgery/date treatment due to commence (Chemo/Radiotherapy)
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)
If patient has had CPET was the outcome satisfactory for them to proceed to Prehab (see tumour-specific patient pathways for more details)?
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
The MUST score
About 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