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Prehab 4 Cancer - Online Referral Form

Fields marked with an * are required fields.

Referrer Details

First name *

Surname *

Phone number *

Email address *

Profession *

Referring organisation *

Patient's personal details

First name *

Surname *

Address *

Town *

County *

Postcode *

Please provide either a mobile number or a landline number. *

Mobile phone number

Landline phone number

Date of birth *

Gender *

Ethnicity *

NHS Number *

Date of cancer diagnosis

Estimated date of surgery/date treatment due to commence (Chemo/Radiotherapy)

Treatment Plan

Please provide details of the following if possible:

Location of the tumor
TNM score
Staging
Proposed treatment option - Please state if this is still under consideration as waiting for tests.
For referrals on the Lung Stage III/IV palliative intent: SACT please provide details on METs and locations.

Incremental Shuttle Walk Test (ISWT) score (if applicable)

Vo2max (if applicable)

Cardiopulmonary Exercise Test (CPET)
Yes No Awaiting CPET

6 Minute Walk Test (6MWT) score (if applicable)

If patient has had CPET was the outcome satisfactory for them to proceed to Prehab (see tumour-specific patient pathways for more details)?
YesNo

Medical History

Please include any relevant information regarding patient's 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:

Height (cm)

Weight (kg)

Weight 3-6 months ago

Weight loss (%)

The MUST score

Acute disease score
YesNo

Are you the patient's GP? *
YesNo

Cancer Consultant's first name *

Cancer Consultant's surname *

Cancer Nurse Specialist's first name *

Cancer Nurse Specialist's surname *

Cancer Nurse Specialist's contact telephone *

Consent

The patient consents to be contacted by the Prehab4cancer Team.

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.

Some of the form fields are required. Please check you have filled out all required fields.

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Cancel

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