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SUSPECTED CANCER REFERRAL FORM: CHILDREN & YOUNG PEOPLEDate of decision to refer:Date referral received at Trust: Trust name(s)Email for referral FORMTEXT ?????Ashford and St. Peter’s NHS Foundation TrustFax: 0800 9234668Email: twrasph@ FORMTEXT ?????Frimley Health NHS Foundation TrustFax: 01276 604506 FORMTEXT ?????Royal Surrey County Hospital NHS Foundation TrustFax: 01483 464848?Email: rsc-tr.TWWAppts@ FORMTEXT ?????Surrey and Sussex Healthcare NHS TrustFax: 01737 231733Patient detailsSURNAME: FIRST NAME: TITLE: GENDER:DOB:NHS NUMBER:ETHNICITY:LANGUAGE: INTERPRETER REQUIRED: TRANSPORT REQUIRED:PATIENT ADDRESS:POSTCODE: CONTACT DETAILS: HOME: MOBILE:EMAIL:GP practice detailsUSUAL GP NAME: PRACTICE NAME: PRACTICE ADDRESS: PRACTICE CODE:DIRECT LINE TO THE PRACTICE (BYPASS):MAIN:FAX: EMAIL: Referring clinician: Patient engagement and availabilityI confirm the following: FORMTEXT ????? I have discussed the possibility that the diagnosis may be cancer FORMTEXT ????? I have provided the patient/parent/guardian with a suspected cancer referral leaflet FORMTEXT ????? I have informed the patient/parent/guardian that the appointment will be within the next 48 hours & attendance is advisedPlease note any dates the patient is NOT available for an appointment in the next 48 hours:Patient’s WHO performance statusGradeExplanation of activity FORMTEXT ?????0Fully active, able to carry on all pre-disease performance without restriction. FORMTEXT ?????1Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work. FORMTEXT ?????2Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours. FORMTEXT ?????3Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours. FORMTEXT ?????4Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair.Cancer type suspected FORMTEXT ????? Haematological FORMTEXT ????? Brain CNS FORMTEXT ????? Neuroblastoma FORMTEXT ????? Wilm’s tumour FORMTEXT ????? Sarcoma FORMTEXT ????? Retinoblastoma IMMEDIATE (via A&E or on-call team)Leukaemia (the Further Information and Guidance section advises when to request a very urgent FBC) FORMTEXT ????? Blood film report suggests leukaemia FORMTEXT ????? Unexplained petechiae or hepatosplenomegalyVERY URGENT (within 48 hours)Hodgkin’s and Non-Hodgkin’s Lymphoma FORMTEXT ????? Unexplained lymphadenopathy (consider) or splenomegaly (consider)(consider associated symptoms e.g. fever, night sweats, pruritus, weight loss or shortness of breath)Brain and central nervous system cancers FORMTEXT ????? Newly abnormal cerebellar or central neurological function (consider)Neuroblastoma FORMTEXT ????? Palpable abdominal mass or unexplained abdominal organ (consider)Wilm’s tumour FORMTEXT ????? Palpable abdominal mass (consider) FORMTEXT ????? An unexplained enlarged abdominal organ (consider) FORMTEXT ????? Unexplained visible haematuria (consider)Bone Sarcoma (the Further Information and Guidance section advises when to request imaging) FORMTEXT ????? X-ray suggests the possibility of bone sarcoma (consider)Soft Tissue Sarcoma (the Further Information and Guidance section advises when to request imaging) FORMTEXT ????? Ultrasound scan suggestive of soft tissue sarcoma (consider) FORMTEXT ????? Ultrasound is uncertain and clinical concern persists (consider)URGENT (within 2 weeks)Retinoblastoma FORMTEXT ????? Absent red reflex (consider) FORMTEXT ?????Consider referral for children if their parent or carer has persistent concern or anxiety about the child’s symptoms, even if the symptoms are most likely to have a benign causeInvestigationsPlease ensure the following recent results are available:Blood test (less than 8 weeks old): FORMTEXT ????? eGFR result _________________Date ____________ Or date of test ____________Free text box for additional clinical information/referral letter:Safeguarding concerns:If this case has been discussed with the secondary care clinical team, please specify with whom, when and advice given:Please use this area to autopopulate a patient summary: to include recent consultations, current diagnoses; past medical history; recent investigations; recent blood test results; medication; any other fields which might be helpful to secondary care.Further information and guidanceUseful websites:CRUK mainCRUK learninge-CDSMacmillanMacmillan learningGenetics and Family HistoryMap of MedicineNICEQ-CancerUseful resources:Signs and symptoms of brain tumours in children information and advice for primary care:Criteria for requesting urgent investigationsSuspected LeukaemiaOffer a very urgent (within 48 hours) FBC for patients with the following unexplained signs/ symptoms:PallorPersistent fatigueUnexplained feverUnexplained persistent or recurrent infectionGeneralized lymphadenopathyUnexplained bruisingUnexplained bleedingPersistent or unexplained bone painSuspected sarcomaGuidance on when to consider direct access imaging≤25yrsSuspected pathological fractureX-Rayvia A&EUnexplained lump increasing in sizeUSS≤48hBone Swelling or Bone PainX-ray≤48h ................
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