East and North Hertfordshire CCG
5725160-13335000-160020-127635HEAD & NECK SUSPECTED CANCER REFERRAL FORMDate of GP decision to refer: Click here to enter a date. No. of pages sent:020000HEAD & NECK SUSPECTED CANCER REFERRAL FORMDate of GP decision to refer: Click here to enter a date. No. of pages sent:IF CHOOSE & BOOK IS UNAVAILABLE, COMPLETE FORM AND FAX/EMAIL TO THE REFERRAL TEAM WITHIN 24 HRS.NOTE: This form is NOT for use for patients aged < 16 years.If your patient does not meet NICE suspected cancer referral criteria, but you feel they warrant further investigation, please disclose full details in your referral letter.PATIENT DETAILS –Must provide current telephone numberLast name: First name:Gender: M ? F ? DOB: NHS No:Address:Telephone (Day):Telephone (Evening):Mobile No.:Patient agrees to telephone message being left? Y ? N ?Transport required? Y ? Email:Interpreter required? Y ? Language/Hearing: Learning difficulties? Y ? Mental capacity assessment required? Y ? Known safeguarding concerns? Y ? Mobility requirements (unable climb on/off bed)? Y ? SYMPTOMS & EXAMINATIONSArea suspected? Oral cavity ? Larynx ? Pharynx? Nasal cavity ? Thyroid ? Other?A red or red-and-white patch in oral cavity consistent with erythroplakia or erythroleukoplakia [2015] ?Lump on lip or in oral cavity unrelated to dental cause ?Persistent ulceration in oral cavity lasting > 3 weeks?IF ≥ 45 yrs WITH persistent unexplained hoarseness AND negative CXR?Persistent lump in neck?Orbital mass Please specify: ? Left ? Right ?Unexplained thyroid lump [2015]**Signs of superior vena cava obstruction (SVCO) or stridor: refer as a medical emergency**ADDITONAL INFORMATIONGP DETAILSGP/Dentist name:Practice Code:Address:Telephone number:FAX:Practice email:INVESTIGATIONS IN SUPPORT OF REFERRALYou don’t need to wait for results of tests to refer.Neck lump? FBC ? ESR ? Glandular fever screen Thyroid ? TFT ? Thyroid antibodies ? Ultrasound Hoarseness? Chest X-rayPlease attach copies of results to completed referral formPATIENT MEDICAL HISTORYRisk factors? Smoker ? Ex-smoker ? Poor diet? Alcohol ? Aged > 45 yearsExisting conditions:Current medication (attach list and indications): Allergies Y ?Anticoagulants/Antiplatelets Y ? Immunosuppressants Y ? Diabetic Y ? WHO Patient Performance status (see below for key)? 0 ? 1 ? 2 ? 3 ? 4DISCUSSIONS WITH PATIENT PRIOR TO REFERRAL?Cancer needs to be excluded?Patient given referral information leafletDate(s) unavailable next 14 days:Please attach a Patient Summary including:? Referral letter (if applicable) ? Investigation results ? PMH ? Up-to date medications list & indicationsWHO PATIENT PERFORMANCE STATUS KEY0Fully active, able to carry on all pre-disease performance without restriction1Restricted in physically strenuous activity but ambulatory and able to carry out light/sedentary work, e.g. house or office work.2Ambulatory and capable of self-care, but unable to carry out work activities. Up and active > 50% of waking hours.3Capable of only limited self-care. Confined to bed or chair >50% of waking hours.4Completely disabled. Cannot carry out any self-care. Totally confined to bed or chair.FOR GUIDANCE ON SYMPTOMS & HOSPITAL CONTACT DETAILS, SEE REVERSE OF THIS FORM.-1725343132PATIENT PRESENTS WITH00PATIENT PRESENTS WITH195580156210ANY OF:00ANY OF:19608807620ANY OF:00ANY OF:340495567945An unexplained thyroid lump [2015]00An unexplained thyroid lump [2015]521970070485IF ≥ 45 yrs WITH hoarseness >3 wks 00IF ≥ 45 yrs WITH hoarseness >3 wks 162941086995Persistent lump in neck, especially if aged >45 years, smokes, drinks alcohol or has a poor diet00Persistent lump in neck, especially if aged >45 years, smokes, drinks alcohol or has a poor diet-21265-1506A red or red-and-white patch in oral cavity consistent with erythroplakia or erythroleukoplakia [2015] 00A red or red-and-white patch in oral cavity consistent with erythroplakia or erythroleukoplakia [2015] 4316730153656SUSPICIOUSNORMALRESULTChest X-rayCONSIDER LUNG PATHWAY00SUSPICIOUSNORMALRESULTChest X-rayCONSIDER LUNG PATHWAY40297405090300163068035418Persistent ulceration in oral cavity >3 weeks00Persistent ulceration in oral cavity >3 weeks128917142240Lump on lip or in the oral cavity00Lump on lip or in the oral cavity1657985146685Orbital mass00Orbital mass2371060100419006124759680800-211418635IF AVAILABLE, refer to dentist(to be seen within 14 days)00IF AVAILABLE, refer to dentist(to be seen within 14 days)61668810809800483743012128500482499512128500-103505154940SUSPECTED CANCER REFERRAL (WITHIN 14 DAYS)00SUSPECTED CANCER REFERRAL (WITHIN 14 DAYS)AngliaBeds & HertsEssexAddenbrookesAdd-tr.nhsoutpatientreferrals@Tel: 01223 596110East & North HertsFAX: 01438 284503If you have not received acknowledgement within 48hrs (Mon-Fri) contact the 2WW supervisor on 01438 285206Basildon & ThurrockFAX: 01268 598066cancer.2wwreferrals@btuh.nhs.uk Bedford HospitalFAX: 01234 792133HinchingbrookeTEL: 01480 847557hch-tr.cancerMDT@Colchester Hospital University FTtwoweek.waitreferral@ Ipswich HospitalFAX: 01473 704120Luton & DunstableFAX: 01582 497910FAX: 01582 497911James PagetFAX: 01493 453325Mid Essex Hospitals FTFAX: 012455 16751QEH, King’s LynnFAX: 01553 613473Norfolk & NorwichFAX: 01603 286876West Herts HospitalsTEL: 01727 897199Wherts-tr.twwreferrals@Southend University Hospital FTFAX: 01702 508174Peterborough & StamfordFAX: 01733 6785622wwreferrals@pbh-tr.nhs.ukWest Suffolk Hospitalwsh-tr.RapidAccess@ ................
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