BCUHB Cancer Related Fatigue services Referral form : Self- referral form

Do you have symptoms of fatigue or excessive tiredness related to your cancer (at any stage) and treatments?

The BCUHB cancer Psychology and Occupational therapy team provide range of support and will attempt to respond as soon as possible.

All information you provide will remain confidential and stored securely in line with Data Protection legislation and the organisation’s Information Governance policies and procedures

By completing this referral form you consent for the Health Board to share necessary and relevant information with your GP or other appropriate healthcare professionals, and to CRF team contacting you.

Thank you

1. Full Name:

2. NHS number or DOB:

3. Home address:

4. Telephone number

5. Consent to contact by Phone

6. E-mail address:

7. Consent to contact via email

8. GP contact details:

9. Name / contact details of CNS/ key worker

10. Consent to contact GP/ CNS for relevant info

11. Relevant cancer diagnosis and treatment

12. Fatigue numerical score. Please indicate the number that best shows how tired you were over the PAST WEEK

0 being No tiredness - 7 - 10 being Worst possible tiredness

please add any other info relevant to your fatigue

13. Have reversible causes of fatigue identified and addressed i.e. anaemia/ thyroid

Yes
NO / unsure – consent to contact GP/ CNS

All information you provide will remain confidential and stored securely in line with Data Protection legislation and the organisation’s Information Governance policies and procedures

By completing this referral form you consent for the Health Board to share necessary and relevant information with your GP or other appropriate healthcare professionals,& to CRF team contacting you. Thank you