Penny Brohn Cancer course November 2019 - Booking Form

Booking Form Thank you for your booking.

Please answer all the questions below as fully as possible. The information you supply will be used to ensure that the time you spend with us is 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 – Your personal details We require these details as a minimum for accessing any of our support services.

Name:

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

Address: Daytime Tel:

l

Mobile Tel: May we leave a message?

Yes ☐ No ☐ Postcode: Email: Female ☐ prefer not to say ☐

Gender: Male ☐

Date of Birth: Which course / event are you booking? (please state type/name of course/event) Please tell us the date want to join

and location

of the course you

Please tell us if you have any health or other problems that may affect your use of Penny Brohn UK Services – e.g. mobility, hearing, language, anxiety etc.

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

Signature

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Date

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Section 1a. Data Protection and your consent A. Permission to store and process your data To help with your booking and to give you the best experience as a client of Penny Brohn UK, we need to record your details. These details may include personal and sensitive data. To comply with the General Data Protection Regulation (GDPR) (EU) 2016/679 we must ask for your permission to store and process your personal and sensitive data for this purpose.

We promise We will always keep your details safe and secure. We will never share your personal information outside of Penny Brohn UK without your permission. Everything you might want to know about how we use and store your details can be found here: pennybrohn.org.uk/privacy-policy.

I consent to Penny Brohn UK recording sensitive personal information about me for the purpose of providing a safe and supportive environment.

Name Signature

Date

B. Research and Evaluation In addition, 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 in showing the impact of services to funders. We need your permission to use your information for this purpose.

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 General Data Protection Regulation (GDPR) (EU) 2016/679.

May we use your data as stated above (Please tick one box)

☐

Yes

No ☐

C. How would you like to hear from us?

Penny Brohn UK really wants to stay in touch with you about our services and products and to tell you about fundraising appeals, events and other opportunities to help. Please tick the boxes below to let us know how we can contact you. Without this information, we cannot contact you at all, so please take a minute to tell us.

Please contact me by post?

Please contact me by telephone?

Please contact me by email?

Please contact me by text message?

Please do not contact me at all

Yes Yes Yes Yes

☐ ☐ ☐ ☐ ☐

No No No No

☐ ☐ ☐ ☐

We understand that your circumstances may change, so if for any reason you need us to change the way we contact you, or it becomes necessary for us to stop contacting you altogether, please let us know by calling 0303 3000 118. (Please note that you will continue to receive bookings’ confirmations and information about the services you attend at Penny Brohn UK through your preferred channels) Page | 2

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Section 1b – Please tell us more about your cancer diagnosis We ask for this information as each experience of cancer is unique. Letting us know what your diagnosis is, and when it was confirmed, helps us to understand your current needs more fully so that we are able to care for you in a safe and supportive way and right for you, right now.

A. Have you been diagnosed with cancer? Yes ☐ No ☐ if no, please go to D. 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 Leukaemia

Stomach

Liver Lung

Uterus Other

Lymphoma Hodgkin

(please give further details)

Testicular

Having a secondary diagnosis will also affect your current needs.

B. Do you have secondary cancer?

Yes ☐

No ☐

When were you diagnosed with secondary cancer?

C. Who should we contact in an emergency?

We ask this in case you are taken ill whilst attending a course, session, or group hosted by Penny Brohn UK. It means we can inform the person named with minimum delay. Please make sure that your named person is aware that you have nominated them as your emergency contact.

Name:

Relationship to you:

Phone Number:

Mobile:

D. Are you supporting someone with cancer?

Yes ☐ No ☐ (if yes please give the name of person you are supporting)

What is your relationship to them?

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Section 2 – Dietary information This section must be completed by anyone (including supporters) attending any course where food will be provided (e.g. single day and residential courses) Please tell us a little about your diet so we provide you with the right food.

Your Diet Do you have any special dietary requirements I am following a special diet (please tick)

Yes ☐ No ☐ (If yes please give details below) These are the foods we normally serve Please tick any that you cannot eat:

Neutropenic diet ☐ Gluten free diet Liquid diet ☐ Low residue diet Other (please give details below)

☐ ☐ ☐

If you are allergic or intolerant to any foods, or have difficulty chewing or swallowing food please give details:

Raw vegetables and fruit Cooked vegetables and fruit Whole grains Nuts and seeds Pulses (peas, beans, lentils) Red Meat Poultry Fish Eggs Other (please give details on the left)

☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

Section 3 – Your Health This section must be completed if you are attending a residential course, individual therapy session or Treatment Support Clinic The following information helps our doctors, nutritionists and therapists understand more about your current state of health so that they give you the right support at the right time.

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 ☐

Start date of treatment

Type/name of drug: 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:

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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 ☐

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No ☐

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Section 3b. Additional information required for people 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 away from home 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 need any additional help while you are here please book to come on your course with someone who can support you. Do please give us a call 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)?

Have you had a general anaesthetic in the last 4 weeks?

Will you have a wound, perhaps from surgery, which will still need nursing or medical attention?

☐ Will you have a PIC line or similar?

☐

☐ Do you get panic attacks?

☐

☐ 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

For office use only: referred to NT? Comments:

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Section 4 – Research and Evaluation: a bit more about you (This section is optional) This information helps us to apply for funding for our services and to make sure we are reaching as many people who need us as possible. Major funders ask us to provide evaluation of our work. Any data we provide to funders is anonymised.

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

Mixed / Multiple ethnic groups 5.White & Black Caribbean 6.White & Black African 7.White & Asian 8.Any other mixed / multiple ethnic background (please describe)

18.Any other ethnic group (please describe)

☐ ☐ ☐

Black / African / Caribbean / Black British 14.African 15.Caribbean 16.Any other Black / African / Caribbean background (please describe)

☐

☐

☐ ☐ ☐ ☐ ☐

☐ ☐ ☐

Arab ☐ 17.Arab

Do you consider yourself disabled?

Yes ☐ (Please give details below) No ☐ Prefer not to say ☐

What is your first or main language? (What language do you speak at home?)

English ☐ Prefer not to say ☐ Other ☐ (Please state below)

What is your sexual orientation?

Heterosexual

☐ Bisexual

Lesbian ☐ or Gay

☐ Other

☐

Prefer not to say

☐

Please tell us your Relationship Status: Single ☐ Living with partner ☐ Married☐ Separated ☐ Divorced ☐ Widowed ☐ Other (please state) ☐ Continued on next page

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What is your occupation / previous occupation?

Do you have a faith/spiritual belief? (please tick one) Agnostic ☐ Buddhist ☐ Atheist ☐ Baha’i ☐ Humanist ☐ Jewish ☐ Mixed Faith ☐ ☐ Islam Spiritual Other ☐ Prefer not ☐ ☐ ☐ None Please to say state:

☐ ☐

Christian Pagan

Hindu Sikh

☐ ☐

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 state)

Please tell us how you first heard about Penny Brohn UK? This information is really important in helping us to target our marketing and use our resources efficiently to raise awareness of our services for people with cancer and their families. ☐ Hospital Team Penny Brohn staff at ☐ hospital

☐ Support Group

☐

Word of Mouth

☐

☐ Online Search

☐

Another website

☐

Cancer Information Centre

Genesis Care ☐ centre

Newspaper/Magazine ☐ article **

☐

Picked up a Penny Brohn information leaflet **

☐

Other ***

☐

GP Practice Advert **

** Please tell us more about where you saw the advert or article or where you picked up the Penny Brohn leaflet. *** Please tell us more about Other

Penny Brohn UK, Chapel Pill Lane, Pill, Bristol BS20 0HH Switchboard: +44 (0)303 3000 118 Fax: +44 (1)1275 370 101 Email: info@pennybrohn.org.uk www.pennybrohn.org.uk 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)

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Terms and Conditions Things you need to know before using Penny Brohn UK Services When you sign the Booking form, you are confirming you agree to these Terms and Conditions which apply to all our services

Please keep this sheet for future reference.

I fully understand that: 1.

Penny Brohn UK does not claim to treat or cure cancer.

2.

The services offered at Penny Brohn UK are intended to support the physical, mental, emotional and spiritual health and wellbeing of adults diagnosed with cancer and people in a close supporting role to them.

3.

The services offered at Penny Brohn UK are compatible with orthodox medical, surgical and drug treatment of cancer and are intended to complement these.

4.

Penny Brohn UK does not at any time undertake medical responsibility for any client, nor does it provide or administer dressings or medicines or carry out any medical procedures or treatments.

5.

Staff at Penny Brohn UK are fully trained, qualified, insured and supported. They offer information, guidance, counselling and complementary and exercise therapies through one to one and group support in good faith to the best of their abilities, without guarantee of a specific outcome.

6.

There is an evidence base supporting the use of all therapies and other interventions offered at Penny Brohn UK, which are generally agreed to be safe for people with cancer. There is a risk that some clients may experience minor adverse effects from some therapies. In attending a therapy session you give your consent to treatment and accept this risk.

7.

Penny Brohn UK holds notes on all clients, in accordance with our Confidentiality Policy and with the Data Protection Act (1998). You have the right to see the information we keep on file about you and to see our Confidentiality Policy.

8.

Confidentiality is held within the Services Department. This means information about you is shared with the therapists you see.

9.

Penny Brohn UK maintains up to date internal policies regulating provision of all aspects of its service, including a comprehensive Complaints Policy which is available on request.

10.

Penny Brohn UK reserves the right to refuse service at any time.

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)

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T&Cs 07/2017