This questionnaire was developed in partnership with Macmillan Cancer Support.

πŸ’¬ Enrolment SMS:

Once the patient has accessed the link, they will be prompted to enter their date of birth in order to access the questionnaire πŸ“†


1. Which of the following treatments have you received?

Choose all that apply (you can select none)

  • Chemotherapy

  • Radiotherapy

  • Immunotherapy

  • Surgery

  • Hormone therapy

2. Are any of the following symptoms affecting your quality of life that you would like to discuss?

Choose all that apply (you can select none)

  • Bowel/Bladder problems

  • Tiredness

  • Pain/Discomfort

  • Sleep problems

  • Appetite weight problems

  • Sexual problems

  • Other

(If the patient selects "Other")

3. What other symptoms are affecting your quality of life that you would like to discuss?

  • Free text box

4. Are any of the following bothering you that you would like to discuss?

Choose all that apply (you can select none)

  • Anxiety or low mood

  • Concerns about work

  • Worry about your loved ones/family

  • Thinking about the future

  • Concerns about finance

5. Your GP or nurse can be useful to discuss planning for the future. Is this something you would like the opportunity to do?

  • Yes

  • No

6. What is your smoking status?

  • Current smoker

  • Ex-smoker

  • Never smoked

(If the patient selects current smoker)

7. How much do you smoke?

  • < 1 cigarette or equivalent per day

  • 1-9 cigarettes or equivalent per day

  • 10-19 cigarettes or equivalent per day

  • 20-39 cigarettes or equivalent per day

  • 40+ cigarettes or equivalent per day

8. Do you drink alcohol?

  • Yes

  • No (questionnaire ends)

(If selected "yes" to the previous question only)

9. How often do you have a drink containing alcohol?

  • Never

  • Monthly or less

  • 2-4 times per month

  • 2-3 times per week

  • 4 or more times per week

When saved back to record - "Frequency of drinking alcohol: 2-4 times per month"

10. How many units containing alcohol do you drink on a typical day when you were drinking?

(1 pint of beer is approximately two units, and one small glass of wine is 1 unit)

  • 1 or 2 units (Light drinker - 1-2u/day - 160575005)

  • 3 or 4 units (Moderate drinker - 3-6u/day - 160576006)

  • 5 or 6 units (Moderate drinker - 3-6u/day - 160576006)

  • 7 to 9 units (Heavy drinker - 7-9u/day - 160577002)

  • 10 or more units (Very heavy drinker - greater than 9 units/day - 160578007)

When saved back to record - "Units of alcohol drunk on a typical day: 3-4 units"

11. How often did you have 6 or more units if female or 8 or more if male, on a single occasion in the past year?

  • Never

  • Less than monthly

  • Monthly

  • Weekly

  • Daily or almost daily

When saved back to record - "Drank greater than 6/8(F/M) units in the past year: Monthly"

12. What type and amount of activity is involved in your work?

  • I am not in employment (e.g. retired, retired for health reasons, unemployed etc.)

  • I spend most of my time at work sitting (such as in an office)

  • I spend most of my time at work standing or walking. However, my work does not require much intense physical effort (e.g. shop assistant, hairdresser, security guard, childminder etc.)

  • My work involves definite physical effort including the handling of heavy objects and use of tools (e.g. plumber, electrician, carpenter, cleaner, hospital nurse, gardener, postal delivery workers etc.)

  • My work involves vigorous physical activity including handling of very heavy objects (e.g. scaffolder, construction worker, refuse collector, etc.)

13. During the last week, how many hours did you spend on physical exercise such as swimming, jogging, aerobics, football, tennis, gym, workout etc.

  • None

  • Some but less than 1 hour

  • 1 hour but less than 3 hours

  • 3 hours or more

14. Is there anything else you would like to discuss in your Cancer Care Review?

  • Free text answer

When they have submitted their answers they will be thanked for completing the survey and sent a confirmation SMS πŸ‘‡

Response in the Accurx Desktop toolbar: Cancer Care Team πŸ‘‡

Please then select the save to record button if you wish for these results to be saved to the patient's medical record πŸ“š

SNOMED codes saved to record

The codes added are in bold and italics

Chemotherapy 367336001

Radiotherapy 419815003

Immunotherapy 76334006

Hormone Therapy 169413002

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