Patient details - Leeds TH



Patient detailsReferring clinicianFirst Name: Surname: NHS number: Address: Patient Telephone: General Practitioner: Current location: Referring Hospital: Ward (if applicable): Referring Consultant: Email: Telephone: Date of referral: Provisional diagnosis: Patient aware of diagnosis? Is patient on a 62 day pathway? FORMTEXT ?????If Yes, 62 day target date: FORMTEXT ?????Presenting symptomsBloodsQuestions for MDT & Additional information FORMCHECKBOX Abdominal Mass FORMCHECKBOX Altered bowel habit FORMCHECKBOX Anaemia FORMCHECKBOX Ascites FORMCHECKBOX Dark Urine/Pale Stools FORMCHECKBOX Dyspepsia FORMCHECKBOX Encephalopathy FORMCHECKBOX Jaundice FORMCHECKBOX Liver Decompensation FORMCHECKBOX Nausea / Vomiting FORMCHECKBOX Pain FORMTEXT Please specify site FORMCHECKBOX PR bleeding FORMCHECKBOX Pruritus FORMCHECKBOX Heamatemesis/melaena FORMCHECKBOX Weight lossx Other FORMTEXT Please specifyBilirubinALT AlkP AlbumineGFR Prothrombin timeHaemoglobinPlatelets If available:CEA AFP CA125 CA19-9 Viral Serology Autoimmune screen FORMCHECKBOX >60 value if <60 FORMTEXT ?????eGFR date: FORMTEXT ?????Comorbidities & performance statusTreatment FORMCHECKBOX Viral hepatitis FORMCHECKBOX Chronic liver disease FORMCHECKBOX Pancreatitis FORMCHECKBOX Autoimmune disease FORMCHECKBOX Inflammatory bowel disease FORMCHECKBOX PSC/PBC FORMCHECKBOX Obesity FORMCHECKBOX Ischaemic heart disease FORMCHECKBOX Respiratory disease FORMCHECKBOX Anticoagulant therapy FORMCHECKBOX Alcohol excess FORMCHECKBOX Diabetes FORMCHECKBOX Haemochromatosis FORMCHECKBOX Bowel resection FORMTEXT (operation type, date) FORMCHECKBOX Liver resection FORMTEXT (operation type, date) FORMCHECKBOX Chemotherapy FORMTEXT (type, date) FORMCHECKBOX Radiotherapy FORMTEXT (type, date) FORMCHECKBOX Transplant FORMCHECKBOX TACE FORMTEXT (type, date) FORMCHECKBOX PVE FORMTEXT (type, date)ECOG performance status FORMDROPDOWN Do you consider your patient fit for surgery? FORMDROPDOWN Do you consider your patient fit for chemotherapy? FORMDROPDOWN Intervention already performedHistopathology available FORMDROPDOWN FORMCHECKBOX ERCP FORMCHECKBOX PTC FORMCHECKBOX +Plastic stent FORMCHECKBOX +Metal stent FORMCHECKBOX Biliary drain FORMCHECKBOX BiopsyHistopathology summary (if available): FORMTEXT ????? ................
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