Cancer Care Review

Last Updated: 13/08/2020

Personal Details

First name *

Surname *

Date of birth *

Condition

Diagnosis - Please let us know what your understanding of your diagnosis is. *

Therapy - Please outline the treatments you have undergone or are expecting. *

Do you take any regular medications? *

Yes No

Do you understand why you are taking the medications your are taking? *

Yes No

Do you take your medications as prescribed? *

Yes No

Do you experience any side effects of your medications? *

Yes No

If yes, please describe the side effects you experience.

Medical Exemption Certificate

You can get free NHS prescriptions in England with a medical exemption certificate, which: - entitles you to free NHS prescriptions only - doesn't cover dental treatment or help with other health costs - should be shown when you collect a prescription - is valid for five years (or until your 60th birthday, whichever is sooner)

Have you received your medical exemption certificate? *

Yes

Not sure

Not required

Health and Wellbeing

How do you feel your current physical health is? *

How do you feel your current mental health is? *

What is your current weight?

How many units of alcohol do you drink each week?

Do you think you eat a healthy diet? *

Do you take part in physical activities or exercise? *

Do you smoke? *

Never smoked

Ex smoker

Trivial (less than one cigarette per day)

Light (1-9 cigarettes per day)

Moderate (10-19 cigarettes per day)

Heavy (20-39 cigarettes per day)

Very heavy (40+ cigarettes per day)

Roll own cigarettes

Smokes a pipe

Smokes cigars

Concerns or questions

Do you have any concerns or questions?

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