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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: Imaging & Investigations to support referral Prior to referral patients require: A chest x-ray prior to referral, taken with the last 3 months Up to date renal function, taken within the last 3 months Please ensure these are provided if not known or out of date. Most referrals will generate a CT chest request unless the patient is under 40, or has had appropriate imaging within 3 months. The patient’s up-to-date renal function is needed to generate this request. Chest X-ray within last year? EGFR: ________ Where performed (if not SFH) __________________________ Creatinine: ________ Date checked: __________ 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 (e.g. 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 _____________________________ Produced: March 2017 Review Due February 2019