Breast Cancer P/Rehab Form Please enable JavaScript in your browser to complete this form.Name *FirstLastAddress *Date of Birth *Telephone Number *OccupationDo you have any symptoms of Covid-19 or have you been in contact with anyone diagnosed with Covid-19? *NoYesYour Breast Cancer Diagnosis DateCancer Type (If known)Treatments. Please select any that apply to you.ChemotherapySurgeryRadiotherapyReconstruction SurgeryHormonal Therapies:If you have/are undertaking Chemotherapy, please list your Chemo medications if known.If you have undergone (or are due to undergo) surgery, please indicate which type, if known.MastectomyLumpectomyWide Local excisionIf you have undergone (or are due to undergo) reconstruction surgery, please indicate which type, if known.DIEPTRAMLD FlapGracilisSGAP/IGAPImplantsIf you have undergone (or are due to undergo) hormonal therapy, please indicate which type, if known.TamoxifenAromatase InhibitorsIf you have undergone (or are due to undergo) lymph node removal, please indicate which type, if known.Sentinel Lymph NodeAxillary clearanceHave you had any other medical therapies, eg Herceptin, Zolodex, Perjeta, Tykerb? Please give detailsYour past medical history, please tick any that apply.Heart ConditionsHigh Blood PressureAsthmaDiabetesOther (please specify below)Were you in menopause at the time of diagnosis?NoYesAre you a smoker?NoYesAny past surgeries? NoYesIf you answered Yes to the previous question, please give details. Are you experiencing any of the following?Shoulder pain/stiffness/weaknessScar pain/ restrictionsBalance/Dizziness issuesHeadaches/ blurred visionPain in your jointsDecreased strengthDifficulty sleepingDifficulties with function/ exerciseSkin changesFatigueSwelling in the affected limbConstipationLeaking urineSexual Health concernsHot flushes/night sweatsBreathing DifficultiesWhat was your prior level of exercise/fitness/sport?Please list your P/Rehab goalsBy providing the information you have submitted, you consent to the collection and storage of your data as described in the privacy policy, which is available for inspection on request. Please tick the box to confirm your agreement. *AgreeWebsiteSubmit
