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<!-- BEGIN worklist/local/outreach/blpd_questionnaire.tt -->
    <div align="center">
    	<img src='/images/outreach_header.png' alt="" />
    </div>

    <p align="center">
      [% entry.first_name | ucfirst %] [% entry.last_name | upper %]
      :: [% INCLUDE site/nhs_number.tt nhs_number = entry.nhs_number %]
      :: [% entry.dob.strftime('%d.%b.%Y') %]
    </p>
	
  <div class="details">
    <p class="contact">
        Please complete this form and return it with the blood samples.
		In case of any problems with samples or symptoms, please contact or
        Carol Reid or Andy Rawstron on [% c.cfg('settings').service_telno %]
        andy.rawstron@nhs.net    
    </p>
    
    <p>
        <b>B-Lymphoproliferative Disorders Symptom Questionnaire</b>
    </p>
    
    <p>
        <u>Symptoms which can be associated with disease activity:</u>
    </p>
    
    <p>
        <i>
            Enlarged lymph nodes: swelling of nodes/glands that lasts for more
            than 2 weeks. Common areas where the lymph nodes are located and can
            be felt include the groin, armpit, down each side of the neck, under
            the jaw and chin, behind the ears or on the back of the head.��������
        </i>
    </p>
    
	<p>
        Do you have any swollen nodes/glands�� YES [ ]�� NO [ ]
	</p>
    
    <p align="right">
        If yes, is the swelling: Long-standing but stable [ ]���
        New, or� long-standing but getting worse [ ]
    </p>
    
    <p align="right">
        If yes, is the swelling in the: Neck [ ]��� Armpits [ ]��� Abdomen [ ]���
        Groin [ ]
    </p>
    
    <p>
        <i>
            Night Sweats: significant night time sweating that soaks the bed
            clothes and bedding.
        </i>
    </p>
    
    <p>
        Do you have night sweats: ���No [ ]��� Occasionally [ ]��� Often [ ]���
        Often, drenching sweats [ ]
    </p>

    <p>
        If you develop one of these symptoms, or a pre-existing symptom becomes
        significantly worse, please contact us (details above)
    </p>

    <p>
        <u>Other common symptoms:</u>
    </p>
    
    <p>
        <i>Infections:</i>
        Your blood disorder can make you more susceptible to infections. Please
        contact your GP at the first signs of an infections as they will be aware
        that you need prompt access to antibiotic or antiviral drugs.
    </p>
    
    <p>
        <i>Fatigue or tiredness:</i>
        This is a common problem and is often unrelated to your blood disorder.
        The blood tests that we do can detect some causes of fatigue. If we find
        anything, we will let you know whether this should be followed up at
        your local surgery or at the haematology clinic.
    </p>

    <p>
        If you have any other symptoms that you think may be related to the
        blood disorder, please record them overleaf. You should discuss also
        discuss it with your GP if it is a persistent problem that is concerning
        you.
    </p>

    <p>
        <b>Please also complete the general health questionnaire</b>
    </p>
  </div>
<!-- END worklist/local/outreach/blpd_questionnaire.tt -->