Self Referral for Cancer Survivorship Dietetic Clinic
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Self Referral to See a Dietitian
|Full name: | |
|NHS number (if known) | |
|Date of birth: | |
|Address: | |
| | |
| | |
|Telephone number: | |
|What type of cancer have you been treated for? | |
|(e.g. lung, breast, bowel) | |
|Please provide a brief summary of the cancer treatment | |
|you have received: | |
|(e.g. surgery/chemotherapy /radiotherapy) | |
| | |
|Do you have any other medical conditions which affect | |
|your diet or health? | |
|(e.g. diabetes/swallowing problems/coeliac disease/ | |
|food allergies/mobility problems/depression) | |
|Please provide a list of any medications you take: | |
|(include, nutritional supplements, vitamins and herbal | |
|remedies) | |
|Please provide a brief summary of what would you like | |
|to discuss with a dietitian and any specific questions | |
|or concerns you may have: | |
| | |
| | |
| | |
| | |
| | |
| |Weight: __________ Date: _________ Height: __________ |
|How did you hear about us? | |
|Date: | |
Please note that we may need to contact your GP prior to arranging a consultation.
Ensure that you include as much information as possible on the form to enable us to prepare fully.
Referrals may be emailed or sent by post (see below):
Vicky Jane (Dietitian) Email: victoria.jane@nbt.nhs.uk Nutrition and Dietetics, Gate 10, Level 6, Brunel Building,
Southmead Hospital, Southmead, Bristol, BS10 5NB Tel: 0117 414 5428
-----------------------
This clinic provides an opportunity for individuals living with and beyond cancer to meet with a dietitian.
Advice might relate to...
·ð Coping with long term effects of cancer treatment
·ð Altered texture diets • Coping with long term effects of cancer treatment
• Altered texture diets
• Maintaining a healthy weight
• Managing a poor appetite
• Healthy eating to aid secondary cancer prevention
The clinic is held at the Macmillan Wellbeing Centre at Southmead Hospital on Thursday mornings.
Self referral forms are available (e.g. at Living Well Events & on the NBT Cancer Services web page), alternatively please speak to a healthcare professional involved in your cancer care (e.g. Cancer Nurse Specialist/MacMillan Support Worker).
For more information please contact
Vicky Jane (Dietitian) - 0117 414 5428
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