Download 2 week wait cancer referral for suspected lung cancer SFHFT

Sherwood Forest Hospitals NHS Foundation Trust
2 week wait referral for suspected lung cancer
Patient surname:
Referring GP:
Patient forename:
Address:
Date of Birth:
Address:
Telephone:
Postcode:
Fax:
NHS No.:
Date of referral:
Gender:
Home Telephone:
Mobile Telephone:
2 week wait referral criteria (at least 1 must be ticked)
 Smokers/ex-smokers aged >40 with persistent haemoptysis (> 1 week)
 Chest X-ray suggestive of lung cancer or mesothelioma
 Normal chest X-ray where there is a high suspicion of lung cancer/mesothelioma
(eg smoker, elderly, refractory symptoms, clinical signs consistent with cancer)
 Stridor (please consider admission if severe)
 Superior vena cava obstruction (swelling of face and/or neck, with fixed elevation of jugular venous
pressure – please consider admission if severe)
Clinical reason for referral:
To support potential solitary pulmonary nodule follow-up:
Smoking history (pack years): ________ Family history of lung cancer? Yes / No
Previous cancer (where)? Yes /No _____________________________
Imaging
It is expected that patients will have had a chest x-ray prior to referral.
Most referrals will generate a CT chest request unless the patient is under 40, or has had appropriate
imaging within 3 months. In order to generate this request, we need to know the patient’s up-to-date renal
function (within the last 3 months). Please request this if it is not known or out of date.
Chest X-ray? 
Where performed (if not SFH) ___________________________________
EGFR: ________ Creatinine: ________ Date checked: __________