Thank You for Booking with Penny Brohn UK

Booking Form

Thank you for booking with Penny Brohn UK.

Please answer all the questions below. The information we are

asking for helps us make your time with us as safe and supportive

as possible. If you have any difficulty with this form please phone our Bookings team on

0303 3000 118 (option2).

Section 1 – Personal Details

required for everybody using any Penny Brohn UK Services

Name: / Title: (e.g. Mr/Mrs/Miss/Ms/Dr)

Address:


Postcode: / Daytime Tel:
Mobile Tel:
May we leave a message?
Yes No
Email:
Date of Birth: / Gender: Male Female prefer not to say
Please tell us your Relationship Status:
Single Living with partner Married Separated Divorced Widowed
Other (please state) prefer not to say

Which course/ event are you booking?

(please state type/name of course/event)

Please tell us the date and location of the course you want to join

Have you been diagnosed with cancer? Yes No

What type? (Please enter the date of diagnosis against the cancer you were diagnosed with.e.g. Jan 2015)
Date of diagnosis / Date of diagnosis
Bladder / / Lymphoma non-Hodgkin /
Bowel(colon & rectal) / / Melanoma /
Brain / / Ovarian /
Breast / / Pancreatic /
Cervical / / Prostate /
Kidney / / Stomach /
Leukaemia / / Testicular /
Liver / / Uterus /
Lung / / Other /
Lymphoma Hodgkin / / (please give further details) /
Do you have secondary cancer? / Yes No
Do you have any health or other problems that may affect your use of Penny Brohn UK Services – e.g. mobility, hearing, language, anxiety etc?

Are you supporting someone with cancer? Yes No

(if yes please give the name of person you are supporting)

and what is your relationship to them?

Who should we contact in an emergency?

Name: / Relationship to you:
Daytime Tel: / Mobile:

We collect information about how effective our services are in helping people live well with cancer. This gives us a voice in making cancer services better for everyone, and helps us fundraise. We need your permission to use your information.

Data Protection:

I agree that my data and information can be held, accessed and processed by Penny Brohn UK for the purposes of evaluation and research. I also agree that my data can be used anonymously in Penny Brohn UK promotional materials. I understand that all personal data or information I provide to Penny Brohn UK will be kept confidential and that no identifiable personal data will be published, presented or shared with a third party, or made public, without my express consent. I understand that I may withdraw my consent to provide my data at any time without giving a reason. I also understand that my consent is conditional on Penny Brohn UK complying with its duties and obligations under the Data Protection Act (DPA) 1998.

If you do NOT agree to the above please tick here 

I confirm that I have read and understood Penny Brohn UK Terms and Conditions of service (enclosed)

Signature Date

We would like to keep you updated about the work of Penny Brohn UK and its subsidiaries.

Please tick the box if you would LIKE to receive this information by post by email by

SMS or by telephone

(Please note that all correspondence regarding your course will be sent by post, email or SMS.)

Section 2 - Diet
Required for everyone coming on any course where food will be provided (single day and residential courses)
Your Diet (supporters are also asked to complete this section)
Do you have any special dietary requirements Yes No (If yes please give details below)
I am following a special diet(please tick) / These are the foods we normally serve Please tick any that you cannot eat:
Neutropenic diet / Gluten free diet / Raw vegetables and fruit
Liquid diet / Low residue diet / Cooked vegetables and fruit
Other (please give details below) / Whole grains
/ Nuts and seeds
Pulses (peas, beans, lentils)
If you are allergic or intolerant to any foods, or have difficulty chewing or swallowing foodplease give details:
/ Red Meat
Poultry
Fish
Eggs
Other (please give details on the left)

Section 3 - Health

Required for everyone staying overnight on a residential course, coming for an individual therapy session or the Treatment Support Clinic

Your Cancer History

What treatment have you had, are having or is planned?
(please tick relevant treatments and give further details where appropriate)
Primary treatment / Chemotherapy / Type/name of drug: / Start date of treatment

Radiotherapy /
Surgery / Type of operation: /
Other / Details: /
Do you have secondary cancer or recurrence of your primary diagnosis? / Yes No
Please give details of your Secondary diagnosis or recurrence / / Date of diagnosis:
Secondary treatment / Chemotherapy / Type/name of drug: / Start date of treatment

Radiotherapy /
Surgery / Type of operation: /
Other / Details: /
Your General Health (supporters are also asked to complete this section)
Do you have any of the following long-term conditions? Please tick all that apply.
Anxiety / Heart Disease(please give details below)
Asthma / Hypothyroidism (underactive thyroid)
Chronic Fatigue, ME or similar / Hypertension (High Blood Pressure)
Chronic Obstructive Pulmonary Disease / IBS, Colitis or similar
Dementia / Kidney Disease
Depression / Mental Illness (please give details below)
Diabetes / Stroke
Epilepsy / Other (please give details below)
Use this space to tell us more about your condition, or anything else you think we should know about your health history, including previous surgery, accidents or trauma.

Please tell us about any medication you are currently taking including herbs, homeopathic remedies and

vitamin/mineral supplements. (supporters are also asked to complete this section)

Medication / Dose / Frequency

It can be helpful for us to work with your medical team to support you better. Our Doctors would usually write to your GP to let them know you have received support from us.

Name / Surgery or Hospital details(please supply address if known)
GP /
Oncologist
/
Cancer Nurse Specialist
/
I give permission for you to contact my medical team Yes  No

Additional –

Required for people who will be staying overnight on a residential course only

This information helps us look after you while you are here. It can also help you think about whether you are well enough to be here at this time. While we have a nurse on site overnight, we are NOT able to provide any medical treatment or any help with personal care. If you will need any additional help while you are here please book to come on your course with someone who can support you. Do please phone us if you’re not sure or have any questions.

Please think about the date of your course or event. Are any of the following likely to be affecting you at that time?

Do you have a stoma (colostomy, ileostomy, urostomy or similar)? / Will you have a PIC line or similar?
Have you had a general anaesthetic in the last 4 weeks? / Do you get panic attacks?
Will you have a wound, perhaps from surgery, that still needs nursing or medical attention? / Are you likely to be suffering from chronic pain?
Do you have an infection or infectious illness?
Is there anything else you think we should know to help us make your visit here as safe and comfortable as we can? Please also tell us here if you have a DNR order in place. If you do, please bring it with you on your course

Section 4 A bit more about you (Optional)

This information helps us get funding for our services and make sure they reach everyone who needs them. Major funders, including the Big Lottery Fund, ask us to provide it. We anonymise any data we provide to funding organisations

Please tell us your ethnic group: (We collect this data in line with ONS Ethnic Group categories)
(Please select the option that best describes your ethnic group or background)
White / Asian / Asian British
1.English/Scottish/Welsh/Northern Irish/British / 9.Indian
2.Irish / 10.Pakistani
3.Gypsy or Irish Traveller / 11.Bangladeshi
4.Any other White background (please describe) / 12.Chinese
/ 13.Any other Asian background (please describe)

Mixed / Multiple ethnic groups / Black / African / Caribbean / Black British
5.White & Black Caribbean / 14.African
6.White & Black African / 15.Caribbean
7.White & Asian / 16.Any other Black / African / Caribbean background
8.Any other mixed / multiple ethnic background (please describe) / (please describe)
18.Any other ethnic group (please describe) / Arab
/ 17.Arab
Do you consider yourself disabled?
Yes (Please give details) / No / Prefer not to say
What is your first / main language?
English / Other (Please state:) / Prefer not to say
What is your sexual orientation?
Heterosexual / Bisexual / Lesbian or Gay / Other / Prefer not to say
What is your occupation/previous occupation?
What is your faith / spiritual belief (please tick one)
Agnostic / Atheist / Baha’i / Buddhist
Christian / Hindu / Humanist / Islam
Jewish / Mixed Faith / Pagan / Sikh
Spiritual / None / Prefer not to say
Other Please state: /
Have you had support from other Penny Brohn UK services, or other providers?
Penny Brohn UK at Genesis Care
Penny Brohn UK Helpline
Penny Brohn UK Health and Wellbeing Clinic or Patient Support Event
Cancer Nurse Specialist
Macmillan Cancer Support
Maggie’s Centre
The Haven
Other (please say what)
How did you hear about Penny Brohn UK?
GP Practice / Hospital Team / Support Group / Word of Mouth
Advertisement / Penny Brohn staff at hospital / Online Search / Another website
Cancer Information Centre / Genesis Care centre / Newspaper/Magazine article
Other
Penny Brohn UK, Chapel Pill Lane, Pill, Bristol BS20 0HH
Switchboard: +44 (0)303 3000 118 Fax: +44 (1)1275 370 101
Email:
Penny Brohn UK is the trading name of Penny Brohn Cancer Care, a registered charity (no. 284881)and a company registered in England (no. 1835916)

Page | 1 BF05/2017