Download urgent two week referral for suspected head and neck cancer

URGENT TWO WEEK REFERRAL FOR SUSPECTED HEAD AND NECK CANCER TO
PLYMOUTH HOSPITALS TRUST
FOR DENTAL PRACTITIONER REFERRALS ONLY
If patient does not fulfil the criteria- please consider urgent/routine referral or treat/watch and wait approach.
PATIENT DETAILS
Surname:
Forename(s):
Date of Birth:
Age:
Male / Female:
NHS Number:
Address:
Postcode:
Telephone number:
Mobile number:
DENTIST DETAILS
Referring Dentist
and address:
Registered GP:
Practice name/
address:
Postcode:
Telephone number:
Fax number:
Date of Referral:
Translator required
Yes
No
If yes please contact GP Practice
Is patient aware of a possible Cancer diagnosis
Yes
RISK FACTORS
Yes
No
Current Smoker
Never Smoked
Ex Smoker
Tobacco Chewing Habit
Heavy Alcohol Drinker
PRIMARY SYMPTONS Please tick “
” in applicable box
Hoarseness for more than 4 weeks with a normal chest X-ray
Dysphagia persisting >3 weeks
No
Unilateral nasal obstruction particularly when associated with pleural discharge
Unresolving neck mass for >3 weeks
Cranial neuropathies
Ulceration or oral mucosa persisting for >3 weeks
Oral swelling persisting for >3 weeks
All red patches of oral mucosa
All red white patches of oral mucosa
Unexplained tooth mobility (not associated with peridontal disease)
Unresolved neck lumps for >3 weeks
PATIENT DETAILS
Surname:
Forename(s):
Date of Birth:
NHS number:
____________________________________________________________________________
SYSTEMATIC SYMPTONS
Weight loss
Symptoms of anaemia
Other (please state - If details are not included under consultation notes, please attach on
separate referral.)
Additional clinical information including drug history: (please see information below or
attach separately)
Consultation Notes (last 5 days):
CLINICAL INFORMATION SUMMARY
BMI:
BP:
Smoker:
Current Medication:
Repeat Medication:
Known drug
allergies or adverse
effects:
THIS FORM MUST BE FAXED TO (01752) 430912 – PLEASE TELEPHONE
THE 2WW OFFICE ON (01752) 437506 TO ENSURE SAFE RECEIPT.
THIS IS FOR DENTAL PRACTITIONER REFERRALS ONLY
Version:
Date for Review:
03/CAB/Microtest
March 2016
Owner/Name:
Cancer Services