Download Referral form - National Women`s Health

Gynaecology Oncology
MDM Referral Form
Date of Referral:
NHI Number:
Patient Name:
Address:
DOB:
Phone/Mobile:
High Suspicion of Cancer Treatment Target Date:
NB: Incomplete referrals are unable to be processed. Please note on page 2 the minimum set
of pre-referral investigations.
Please EMAIL completed form to [email protected]. Cut-off 12 midday on
Friday for following Wednesday.
REFERRING SPECIALIST
 Consultant name:
 Hospital/DHB:
 Email address:
GP name and address:
HISTORY:
 Age:
 Brief history:
 Co morbidities:
 Tumour markers:
 BMI:
 ECOG score(Circle the right one): 0
 Ethnicity:
1
2
3
4
5
RADIOLOGY:
 Type of diagnostic performed:
 Date that diagnostic performed:
 Location that diagnostic performed:
 Key findings:
Issued by the Northern Midland Gynaecology Oncology Tumour Stream. Updated 02/12/2016 Page 1 of 3
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Type of other diagnostic:
Date of other diagnostic:
Location of other diagnostic:
Key findings:
OPERATION:
 Date:
 Surgeon:
 Procedure:
 Findings:
HISTOLOGY/CYTOLOGY
 Specimen type, e.g., pipelle/cervical biopsy/specimen:
 Date and location of specimen(s):
 Key findings:
WHAT IS THE QUESTION FOR THE MDM?
IS THE PATIENT AWARE OF THE CANCER DIAGNOSIS? Y/N
DATE OF DIAGNOSIS: Minimum set of investigations prior to referral:
Biopsy result:
Carcinoma of the Vulva
CT abdomen and pelvis:
CXR:
Biopsy result:
Carcinoma of the Vagina
FBC, U + E:
MRI:
PET if visible lesion:
Biopsy result:
Carcinoma of the Cervix
FBC, U + E:
MRI:
PET if visible lesion:
Histology (pipelle or curettings):
Endometrial Carcinoma
MRI pelvis and abdomen (If high grade, change to CT CAP):
CXR:
RMI (risk of malignancy index) score:
Pelvic Mass
Abdominal pelvic imaging (CT CAP or MRI + CXR):
CA125, CEA, Ca19-9:
If age < 40 AFP, HCG, LDH:
UEC, LFT, albumin:
Issued by the Northern Midland Gynaecology Oncology Tumour Stream. Updated 02/12/2016 Page 2 of 3
Indications for core biopsy:
 Chest disease
 Large volume upper abdominal disease
 Multiple bowel involvement
 Mesenteric involvement
 Albumin < 20
 Obstruction
 CA 125/CEA ratio < 25
Note 1: USS for Endometrial Carcinoma and Pelvis Mass may be accepted as an alternative to MRI in
exceptional case only (where MRI or CT is not available) with prior agreement with regional service
provider.
Note 2: Date of diagnosis – confirmed by histology +/- radiology
Issued by the Northern Midland Gynaecology Oncology Tumour Stream. Updated 02/12/2016 Page 3 of 3