DOB ____________________________________ Tel: (home) ____________ (cell) ______________
_______________________________________ Referral to Cancer Rehabilitation and Survivorship
Telephone number most easily reached during day
Eligibility Requirements: Patient must be seen by oncologist for cancer treatment at Princess Margaret Cancer Centre Reason for referral must be cancer related impairment Date of Referral: ____________________________
Staff Physician/NP Signature:___________________ ____________________________________________ OHIP Billing Number: ________________________ ____________________________________________ Form Completed by (if different then above):
Reason for Referral (please check all cancer related impairments below) Physical Musculoskeletal ROM Weakness Pain Location: _________________________ Neurological Chemo-induced Peripheral Neuropathy Balance Location: _________________________ Deconditioning Exercise Program Counseling Lymphedema: Location: _______________________ Active Cellulitis: Y N Ruled out DVT: Y N
Cognitive Brain Fog (memory, attention, concentration)
Functional Difficulty with ADLs Fatigue Return to Work/School Sexual Health
Other Explain:_______________________________________
This referral includes a consultation from Dr. Eugene Chang (Physiatrist) as needed. Patients will also be screened for nutrition and psychosocial issues as part of our comprehensive assessment. All services are provided by a transdisciplinary team (occupational therapy, physiotherapy, social work, massage therapy, kinesiology, dietitian, psychology, and neuropsychology).
