Staunton & Corse Surgery NHS GP Surgery in Gloucestershire

Cancer concerns checklist

Required fields are labelled

You must be aged 13 or over to complete this form yourself

Who are you completing this form for?

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

Identifying your concerns

If any of the problems listed have caused you concern recently and you wish to discuss them with a key worker, please select the box and score the concern from 1 to 10, with 10 being the highest. Leave the box and score blank if it doesn’t apply to you or you don’t want to discuss it now.

Confirmation

I have questions about my diagnosis, treatments or effects

Rate 1-10:

Family or Relationship Concerns

Partner

Rate 1-10:

Children

Rate 1-10:

Other relatives or friends

Rate 1-10:

Person who looks after me

Rate 1-10:

Person who I look after

Rate 1-10:

Spiritual Concerns

Faith or spirituality

Rate 1-10:

Meaning or purpose of life

Rate 1-10:

Feeling at odds with my culture, beliefs or values

Rate 1-10:

Information or Support

Exercise and activity

Rate 1-10:

Diet and nutrition

Rate 1-10:

Complementary therapies

Rate 1-10:

Planning for my future priorities

Rate 1-10:

Making a will or legal advice

Rate 1-10:

Health and wellbeing

Rate 1-10:

Patient or carer’s support group

Rate 1-10:

Managing my symptoms

Rate 1-10:

Cancer concerns checklist

Identifying your concerns

Physical Concerns

Practical Concerns

Emotional Concerns

Family or Relationship Concerns

Spiritual Concerns

Information or Support

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Cancer concerns checklist

Identifying your concerns

Physical Concerns

Practical Concerns

Emotional Concerns

Family or Relationship Concerns

Spiritual Concerns

Information or Support