Spinal Oncology Referral Form (PAGE 2 OF 2) Patients Name: DOB TUMOUR SPINE Primary (circle disease site ) Presenting Complaint Breast Bronchus GIT None GU Lymphoma Melanoma Pain only Y / N since (date) Myeloma Prostate Renal Thyroid Uterine/Cx Unknown Location: Other (specify) Type: Non specific Mechanical Postural Date of diagnosis: Pattern: Nocturnal Diurnal Constant Primary Rx Y / N since (date) Neurological Symptoms Y / N since (date) Adjuvant Rx Walking Status 1 Normal Neurological Signs 2 Unsteady since (date) 3 Not ambulant since (date) Previous Metastases Y / N Incontinence Define Urinary Y / N since (date) Faecal Y / N since (date) PR Y / N Anal tone Y / N since (date) Current Staging Sensory Y/N Osseous Mets Y / N Define Since demonstrated by: Lowest MRC grade 0 1 2 3 4 5 Isotope scan -date / Not done Plain Radiographs -date / Not done Muscle Group(s) Since Sites:- MRI (whole spine) Yes / Not done Location Date Time Y / N Visceral Mets demonstrated by: CT Chest /Abdo -date / Not done CXR -date / Not done Liver US -date / Not done Sites:- Other relevant information Senior clinical advisor review (1) Senior clinical advisor review (2) Name:- Name:- Decision: Decision: Details of clinician responsible for ongoing care of the patient following surgery. Name:- Contact Number:-
Spinal Oncology Referral Form (PAGE 2 OF 2) Patients Name: DOB TUMOUR SPINE Primary (circle disease site Breast Bronchus GU Lymphoma Myeloma Prostate Thyroid Uterine/Cx Other (specify) ) GIT Melanoma Renal Unknown Presenting Complaint None Pain only Y / N Location: Type: Non specific Pattern: Nocturnal Neurological Symptoms Neurological Signs since (date) Mechanical Postural Diurnal Constant Y / N since (date) Y / N since (date) Date of diagnosis: Primary Rx Adjuvant Rx Walking Status 1 Normal 2 Unsteady since (date) 3 Not ambulant since (date) Previous Metastases Define Y / N Incontinence Urinary Y Faecal Y PR Y Anal tone Y / N since (date) / N since (date) / N / N since (date) Current Staging Osseous Mets demonstrated by: Y / N Sensory Define Y/N Since Isotope scan -date Plain Radiographs -date / Not done / Not done Lowest MRC grade 0 1 2 3 Muscle Group(s) Since 4 5 Sites:- MRI (whole spine) Yes / Not done Date Time Location Visceral Mets demonstrated by: Y / N CT Chest /Abdo -date Liver US -date / Not done / Not done CXR -date / Not done Sites:- Other relevant information Senior clinical advisor review (1) Senior clinical advisor review (2) Name:- Name:- Decision: Decision: Details of clinician responsible for ongoing care of the patient following surgery. Name:- Contact Number:-