Referral Form for Cancer Exercise Circuits Name DOB Contact details Next of Kin GP Consultant CNS What are your goals or aims for the circuit sessions? (Eg: to get fit for surgery, get back to walking the dogs, back to work, lose weight) What is your current level of activity? Eg: Distance walked, number of active sessions and duration in the week) What was your level of activity prior to your cancer diagnosis? What would you like to get back to doing or take up? 1
Have you been advised of any precautions with regards to you, your cancer or treatments which would impact on what you can and can t do by any Health Care Professional? What cancer were you diagnosed with? Please tick which treatments you have had or are due to have Surgery Dates: Chemotherapy Radiotherapy Stem Cell Transplant Hormone Therapy Other please include details Do you have any pre-existing conditions? Osteoarthritis Musculoskeletal problems eg; neck/back pain Diabetes Cardiac Problems Respiratory/breathing difficulties Osteoporosis Epilepsy High Blood Pressure Thyroid Problems Stroke Claudication Other - details Prior to your cancer diagnosis have you had any other surgery/illnesses or operations? (Please list dates) 2
Has you cancer spread to anywhere else in your body? If you have cancer in your bones do you take bisphosphonates? Yes No Do you take any medications? (Please list) Are you using a PEG feed? Do you have a colostomy bag? Do you have a stoma fitted? Is this temporary or permanent Do you currently struggle with: Pain (please state where) Difficulties moving certain joints eg: the shoulder Fatigue Breathlessness/shortness of breath Weakness (please state where) Loss of balance Peripheral neuropathy (pins and needles in your hands or feet) Steroid induced myopathy Difficulties with weight (either losing or putting it back on please state) Lymphoedema Hot Sweats 3
Incontinence Cording Blood Clots Mucositis oral or oesphageal (mouth ulcers and pain and difficulty swallowing during chemotherapy) Mucositis gastrointestinal (often causes diarrhoea from chemotherapy) Precautions/Considerations: Surgical Wounds/complications or tenderness Pressure sores Low white cell count (less than 3,000) Low Haemoglobin count (anaemic) < 9g/dl Low platelet count (< 50,000) Skin Grafts Reconstruction (please list what and dates) Have you experienced or are currently experiencing: Dizziness Uncontrolled pain Severe tissue reactions to radiotherapy Nausea/vomiting High Fever Pins and Needles in both legs Sudden bowel or bladder changes Numbness around your bottom area Increase in thirstiness Constant night pain that does not resolve with pain relief Extreme fatigue Weight loss of great than 35% of pre-treatment weight (cachexia) *(If you have any of the above please contact your GP/Oncologist/CNS or speak to Clare Lait Specialist Cancer Physiotherapist. These are all potential issues that may need addressing medically. Please do not ignore them. However if you are not sure please talk to us.) * Please do not attend on the day or 24hrs after application of chemotherapy drugs Patient Informed Consent/Disclaimer I agree for the above information to be passed onto the exercise professionals and any concerning information to the named Consultant/GP/Clinical Nurse Specialist should the need arise. I understand that I am responsible for monitoring my own responses during exercise and I will inform the physiotherapist/instructor of any new or unusual symptoms. I will also inform them of any changes in medication or the results of any investigations of treatments. 4
Patients Signature Print Name: OFFICE USE ONLY BP HR at rest Important Information The Patient Exhibits no contraindications to exercise The patient is clinically stable The patient is compliant with medication The patient is awaiting/not awaiting further medical or surgical treatment include details Referrers signature Print Name: Please return the form to: Clare Lait -Specialist Cancer Physiotherapist The Ladies College Sport Centre Malvern Road Cheltenham GL50 2NX 5