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HCP Referral Form

Penny Brohn UK Preparing for Treatment Programme

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If you are a service user and want to see if you are eligible then please complete our self referral form

Before submitting a referral, please review our service criteria carefully. If your patient meets any of the exclusion criteria listed, they would not be suitable for our service at this time.

As a small charity with limited capacity, we are unable to process or respond to referrals that fall outside our remit. Thank you for helping us ensure that patients are directed to the most appropriate specialist support.

Please note: as our Preparing for Treatment service is delivered online, our eligibility thresholds may differ slightly from in-person services. Thank you for keeping this in mind.

NUTRITION CRITERIA

Please review the following before making a referal.

If the answer is YES to any of the following, the patient is not appropriate for our service. Please refer instead to your local specialist Dietitian Service.

  • MUST Score> 2 or PGSGA SF score > 4+
  • Poor oral intake 
  • Low BMI (< 18.5kg/m2) 
  • Dysphagia 
  • Uncontrolled diabetes management 
  • Poorly managed symptoms e.g. Nausea, vomiting, diarrhoea, high output stoma 
  • Recent recommendation for dietary modifications for cancer related issues e.g. low fibre for risk of bowel obstruction, electrolyte restrictions 
  • Ongoing issues related to pancreatic exocrine insufficiency e.g. taking Creon / Nutrizym tablets and still experiencing steatorrhoea

PHYSICAL ACTIVITY CRITERIA

Please review the following before making a referal.

If the answer is YES to any of the following, the patient is not appropriate for our service. Please refer instead to your local specialist Physiotherapy Service.

  • Clinical Frailty Score ≥ 5
  • DASI (Duke activity status index score) <25
  • Fallen in the past 3 months 
  • Severe Impairment and/or disability 
  • Low Functioning levels/ cardiac or respiratory issues
  • Significant distress
  • High risk of deterioration in function

If you are happy the client DOES NOT require support from specialised services then please continue with the referral form. If you need to discuss it further, please do not hesitate to contact us at prehab@pennybrohn.org.uk 

Which service are you referring for? Tick which apply:

Please note

If referring for support with Physical Activity- Is the patient cleared to exercise by their oncology team?
Has the patient consented to the referral?
If no, please ensure you gain consent from the patient before proceeding with this referral
I confirm that I have discussed and obtained the patient's informed consent for the NHS and Penny Brohn UK to share relevant personal information as necessary to escalate concerns or to review services, in accordance with applicable data protection regulations

Patient details

Name
Address

Referrers Details

Name

Cancer Diagnosis and Treatment

Past Medical History

Please tick all that apply
If you have ticked Myocardial Infarction, please let us know if it was in the last 3 months.

If known, please provide the relevant nutrition score you use for your Trust

SIGN

I confirm that I have reviewed the Penny Brohn UK Preparing for Treatment criteria, and to the best of my knowledge, this patient is appropriate for assessment by the Penny Brohn UK team.
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