Cancer Concerns and Care Review

Your Details

Your First Names: *

Your Last Name: *

Your Date of Birth: *

Please use this date format: DD/MM/YYYY.

Your Phone Number: *

Your Email: *

Condition

Please let us know what your understanding of your diagnosis is. If you have a specific question, we will try and answer this for you.

Please let us know what treatments you have undergone e.g. chemotherapy, radiotherapy or surgery. Are there any treatments your are still expecting? Please ask if you have any specific questions about your treatment that we can help with.

Do you take regular medication?

Yes

No

This includes prescribed and over-the-counter medicines.

Health and Wellbeing

Current physical health:

If you suffer from any physical symptoms such as pain, nausea, constipation, sweating or others, please let us know. We will aim to give you specific advice for these if we can. Remember to contact the practice directly if you feel your symptoms require urgent attention.

Current mental health:

Many people with cancer will feel worried and anxious about their situation. There are support groups available so please let us know if you require any help with this. Please do not enter anything that requires urgent attention.

Do you think you eat a healthy lifestyle?

A healthy lifestyle can help your body recover after treatment. It can also help to reduce the risk of other illnesses, such as heart disease, diabetes and strokes. Consider whether you have regular meals, fruits and vegetables, the number of takeaways.

Do you take part in any physical activity or exercise?

During treatment, people are often less active than usual. This can make you feel more tired and your muscles lose some strength. Even some regular physical activity such as short walks, can help give you more energy, make you feel stronger and improve stress or anxiety. You can gradually build up how much activity you do. Make sure you don’t do too much as this can make you feel more tired. Aerobic activity such as fast walking, running, skipping, cycling, dancing and swimming can help to protect your heart. This may also help reduce the risk of late effects developing.

Weight (in kg): *

Height (in cm): *

Alcohol Consumption

This is one unit of alcohol:

Amount of different types of drink representing one unit of alcohol

And each one of these, is more than one unit:

Amount of different types of drink representing more than one unit of alcohol

How often do you have a drink containing alcohol? *

How many units of alcohol do you drink on a typical day when you are drinking? *

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? *

Smoking

Do you smoke? *

Never smoked

Ex smoker

Trivial (less than one cigarette per day)

Light (1-9 cigarettes per day)

Moderate (10-19 cigarettes a day)

Heavy (20-39 cigarettes a day)

Very heavy (40+ cigarettes a day)

Please provide further details:

If relevant please enter your daily average. Please include if you smoke a pipe, cigars or roll your own tobacco.

Anything else to add?

How would you like to complete your review?

I would like to discuss things further and I will contact the practice to arrange this

I am happy for a clinician to see my responses and complete my review without further discussion if appropriate

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Your Details

Condition

Health and Wellbeing

Alcohol Consumption

This is one unit of alcohol:

And each one of these, is more than one unit:

Smoking

Healthwatch Oxfordshire