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<!-- BEGIN worklist/local/outreach/mgus_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>Monoclonal Gammopathies Symptom Questionnaire</b>
    </p>
    
    <p>
        <u>Symptoms which can be associated with disease activity:</u>
    </p>
    
    <p>
        <i>
            Bone pain: aching or other discomfort in one or more bones.
            This does not include arthritic or muscular aches and pains.
            Bone pain associated with disease activity would be persistent,
            i.e. it would not come and go.��������
        </i>
    </p>
    
	<p>
        Do you have any bone pain�� YES [ ]�� NO [ ]
	</p>
    
    <p align="right">
        If yes, is the bone pain: Long-standing but stable [ ]���
        New, or� long-standing but getting worse [ ]
    </p>
    
    <p align="right">
        If yes, is the bone pain in the: Ribs [ ]��� Back [ ]��� Upper Arms [ ]���
        Upper Legs [ ]    Other [ ]
    </p>
    
    <p>
        If you develop one of these symptoms, or a pre-existing symptom becomes
        significantly worse, please contact us (details above)
    </p>
    
    <p>
        <i>
            Symptoms that are extremely rare but need to be dealt with urgently
            include: numbness, loss of feeling or paralysis of lower limbs;
            urinary and fecal incontinence and/or urinary retention. Any of these
            symptoms should be reported immediately to your GP or contact NHS Direct.��������
        </i>
    </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/mgus_questionnaire.tt -->