Physical Activity Referral Form

Physical Activity Referral Form

On Views / Part
Full
Membership
First session
Induction

Referrer to complete sections 1 & 2 only

1. Patient Details (referrer to complete)

Name / Telephone
Title / Mr / Mrs / Ms / Dr / Date of birth / / / / Gender /

Male / Female

Address
Postcode / Email

Patient: If you are completing this form yourself, please put ‘self’ in the referrer name section below and also cancer diagnosis then proceed to section 3

1. Referrer Details (referrer to complete)

Name of referrer / Job title
Location / Contact number
Signature / Date
Cancer diagnosis / Prostate / Breast / Colorectal / Other (please state)

1. Medical History (patient to complete)

Cancer treatments Please add dates / Chemotherapy
Radiotherapy
Targeted therapy
Hormonal therapy
Surgery
Medications
Please continue a separate sheet
Any side effects experienced?
Please tick allthat apply / Osteoporosis
Lymphoedema
Cardiotoxicity
Fatigue
Limited range of movement
Depression and/or anxiety / Any limitations
Future cancer treatments planned? / Osteoperosis
Cardiotoxicity
Fatigue / Lymphoedema
Limited range of movement
Other medical conditions

1. Ethnicity

White: British / Asian or Asian British: Bangladeshi
White: Irish / Asian or Asian British: Other Asian
White: Other White / Black or Black British: Caribbean
Mixed: White and Black Caribbean / Black or Black British: African
Mixed: White and Black African / Black or Black British: Other Black
Mixed: White and Asian / Chinese or other ethnic group: Chinese
Mixed: Other Mixed / Other ethnic group: Other Ethnic Group
Asian or Asian British: Indian / Not specified
Asian or Asian British: Pakistani

1. Emergency Contact Details

Name / Relationship
Address (if different from above) / Contact Number(s)

1. Consent

Self-Referral Declaration (pre and during treatment)

If I am receiving, or about to receive any of the following treatments: chemotherapy, radiotherapy, targeted therapy, hormonal therapy or surgery – I will consult with my clinical specialist nurse specialist prior to starting the physical activity programme. Should there be something that affects my ability to exercise or I have a change in medication, I will inform the instructor immediately and stop exercising if necessary.

Please tick to agree

Data Protection

We keep your records confidentially and securely. From time to time, our partners ask for information for monitoring & evaluation purposes to help us improve our service. Please tick this box if you consent to this

Filming and Photo Consent

I understand that from time to time, photographs or filming will be taken during the session. All such official photographs and filming will only take place by a Notts County Fitcapproved personand used to promote the CARE programme. Please tick this box if you consent to this

Print Name______Signed______Date______

Forenquiries please telephone:

Rob Russell (CARE Coordinator) 07534135670

or

Emma Trent (Health Manager) 0115 9055896

Post to:

Rob Russell – CARE Programme Coordinator

Portland Centre, Muskham Street, Meadows, Nottingham, NG2 2HB.

Email scanned forms to: