Suspected Breast Cancer Referral Form Patient Details Surname: Date of Birth: Forename(s): Gender: Address (inc postcode): NHS Number: Telephone Numbers Tel No (Home): Tel No (work): Tel No (Mobile): Please check tel no's with patient GP Details Referring GP: GP Tel No: Practice Name: Practice Email Address: Practice Address: Date of decision to refer: Patient Information Does your patient have a learning disability? Yes No Is your patient able to give informed consent? Yes No Is your patient fit for day case investigation? Yes No If a translator is required, please specify language: Is patient on any of the following medications? Aspirin Yes No Indication for therapy: Clopidogrel /Prasugrel etc . Yes No Indication for therapy: Warfarin Yes No Indication for therapy: NOAC (Rivaroxaban etc.) Yes No Indication for therapy: Insulin Yes No It would be helpful if you could provide performance status information (please tick as appropriate) Fully active Able to carry out light work Up & 50% of waking time Limited to self-care, confined to bed/chair 50% No self-care, confined to bed/chair 100% Please confirm that the patient is aware that this is a suspected cancer referral: Yes No Date(s) that patient is unable to attend within the next two weeks: If patient is not available for the next 2 weeks, and aware of nature of referral, consider seeing patient again to reassess symptoms and refer when able and willing to accept an appointment. The above details are required before we can begin booking appointments of Cancer Concern (completion optional) All patients should meet NICE guidelines for suspected cancer 2015 very concerned that my patient has cancer” “I’m unsure, it might well be cancer but there are other equally plausible explanations.” “I’m don’t think it likely that my patient has cancer but they meet the guidelines.” “I Reasons for referring Please detail patient and relevant family history, examination and investigation findings, your conclusions and what needs excluding or attach referral letter. Referral Criteria Suspected Cancer Referral
Suspected Breast Cancer Referral Form Patient Details Surname: Date of Birth: Forename(s): Gender: Address (inc postcode): NHS Number: Telephone Numbers Please check tel no's with patient Tel No (Home): Tel No (work): Tel No (Mobile): GP Details Referring GP: GP Tel No: Practice Name: Practice Email Address: Practice Address: Date of decision to refer: Patient Information Does your patient have a learning disability? Yes No Is your patient able to give informed consent? Yes No Is your patient fit for day case investigation? Yes No If a translator is required, please specify language: Is patient on any of the following medications? Aspirin Yes No Indication for therapy: Clopidogrel /Prasugrel etc . Yes No Indication for therapy: Warfarin Yes No Indication for therapy: NOAC (Rivaroxaban etc.) Yes No Indication for therapy: Insulin Yes No It would be helpful if you could provide performance status information (please tick as appropriate) Fully active Able to carry out light work Up & 50% of waking time Limited to self-care, confined to bed/chair 50% No self-care, confined to bed/chair 100% Please confirm that the patient is aware that this is a suspected cancer referral: Yes No Date(s) that patient is unable to attend within the next two weeks: If patient is not available for the next 2 weeks, and aware of nature of referral, consider seeing patient again to reassess symptoms and refer when able and willing to accept an appointment. The above details are required before we can begin booking appointments of Cancer Concern (completion optional) All patients should meet NICE guidelines for suspected cancer 2015 “I’m very concerned that my patient has cancer” “I’m unsure, it might well be cancer but there are other equally plausible explanations.” “I don’t think it likely that my patient has cancer but they meet the guidelines.” Reasons for referring Please detail patient and relevant family history, examination and investigation findings, your conclusions and what needs excluding or attach referral letter. Referral Criteria Suspected Cancer Referral
cancer-2ww-proforma-breast.docx