My Key To Care
Please note, this page is printable by selecting the normal print options on your computer.
My Key To My Care
A guide to unlocking discussions with the healthcare team on your current holistic needs.
Name: ……………………………………………………………….
Date: ………………………………………..
Over the past week what have been your main problems or worries?
| 1 |
| 2 |
| 3 |
Have any of the following affected you over the last week?
| Not at all (0) | Slightly
(1) |
Moderately
(2) |
Severely
(3) |
|
| Pain or discomfort |
|
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| Tingling in hands/feet | ||||
| Breathlessness |
|
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| Lack of energy |
|
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| Poor appetite |
|
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| Nausea |
|
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| Vomiting |
|
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| Diarrhoea |
|
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| Constipation |
|
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| Sore/dry mouth |
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| Drowsiness |
|
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| Poor sleep |
|
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| Poor memory/ concentration | ||||
| Other symptoms:
|
How do you feel on this scale?
1………………………………………………………………………………………………………………..10
Really poorly Really well
Over the past week
| Not at all
(0) |
Sometimes
(1) |
Most of the time
(2) |
Always
(3) |
|
| Have you been feeling worried or anxious? |
|
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| Have your friends /family been worried about you?
|
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| Have you felt depressed? | ||||
| Have you had as much information as you wanted? | ||||
| Have any practical problems resulting from your cancer (e.g. financial) been addressed? |
Thank you for taking the time to complete this assessment tool.
Your Macmillan Cancer Nurse Specialist will arrange a time and date convenient for you to discuss your response in this document further.
Your Macmillan Cancer Nurse is ……………………………………………………………….
Contact Number ………………………………………………………………..
In the meantime if you wish to discuss any further concerns raised in this document you can call the Macmillan Wellbeing team based in the
Irene Crosswell Macmillan Wellbeing Lounge, based on the Ground Floor of the Cancer Centre on 01908 996563.
Key contact Numbers
Cancer Centre Helpline: 01908 997634
Cancer Centre Reception: 01908 996351
Cancer Centre Chemotherapy Suite: 01908 996561
If you are concerned regarding any of your symptoms or feel unwell, please call the Acute Oncology / Haematology Contact: 01908 660033 Bleep 1090
to discuss further and for assessment.
Macmillan Cancer Support: 0800 808 00 00