01823 343 417 01935 384 640

GP REFERRAL PROFORMA FOR SUSPECTED CANCER - GYNAECOLOGICAL CANCER
PLEASE USE 2WW SERVICE ON CHOOSE & BOOK OR FAX TO 01823 343 417 / 01935 384640
This form should only be used for patients who meet the NICE referral criteria for suspected cancer (2005)
Do not use this form for non-suspected cancer referrals.
Decision to refer date: / .------/ ------/ ------/ Referral received date: / .------/ ------/ ------
Has the patient been informed that they are being referred for suspected cancer?
Please inform the patient that they will be offered an appointment / test within 14 days of receipt of referral (NB first test may be an USS).
Dates patient unavailable in next 14 days:
Has this referral been delayed by over 24 hours from decision to refer?
Reason for delay: /  Yes
 No
------
 Yes
 No
Patient details: / Referring GP (use practice stamp if available):
Surname: / Name:
Forename: / Practice:
Address:
Hospital No.: / DOB:
NHS No.:
Telephone No. Day / Telephone No.:
Mobile: / Fax No.:
Work / E-mail address:
If USS has been performed please attach report
Patients must meet one or more of the following criteria: / Date of USS: ------/ ------/ ------
OVARY:
Palpable abdominal or pelvic mass not obviously fibroids
Suspicious pelvic mass on ultrasound
NB: Please take CA125 blood test at time of referral to speed diagnosis, and confirm taken here 
Women under 40 years require hCG, AFP and LDH in addition  / UTERUS:
Not on HRT with postmenopausal bleeding
Persistent or unexplained postmenopausal bleeding after cessation of HRT for 6 weeks
Taking Tamoxifen with postmenopausal bleeding
CERVICAL:
 Clinical features suggestive of cervical cancer
 Persistent post coital bleeding with negative pelvic examination in a woman over 35 years old. / VULVA:
Unexplained vulval lump
Vulval bleeding due to ulceration
Persistent vulval pruritus or pain despite a period of ‘treat, watch and wait’ (consider non-urgent referral depending on degree of concern re cancer)
All other referring symptoms (e.g. abnormal peri-menopausal bleeding, two or more unscheduled bleeds on HRT, routine cervical smear test which has a severe / moderate dyskariosis and / or glandular neoplasia, persistent post coital bleeding in woman < 35 years) should be referred by Choose and Book or letter to the Gynaecology Dept.
Please indicate if speculum/VE performed  and note below/overleaf details of clinical findings, symptoms, any significant medical history, co-morbidities, current medication, known allergies, recent blood results and any other relevant information. Referrals without adequate clinical information may delay or result in a declined referral.
Thank you.
Please record WHO STATUS: 

TAUNTON AND SOMERSET NHS FOUNDATION TRUST VERSION 4(Mar 2011)

YEOVIL DISTRICT HOSPITAL NHS FOUNDATION TRUST