Sherwood Forest Hospitals (NHS) Trust
KINGS MILL and NEWARK HOSPITAL
2 WEEK WAIT CANCER REFERRAL FOR SUSPECTED GYNAECOLOGICAL MALIGNANCY
For Trust use only – Confirmation of Electronic Referral Information
Hospital Number: / Date of Appointment: / Time:
Speciality: / Consultant:
Patient Details / Practice Details
NHS No.: / Referring GP:
Surname: / Organisation
Forename (s): / Telephone Number
DOB:
Previous Surname: / Registered GP:
Address: / GP Practice Address:
Sex: / GP Phone Number:
Marital Status: / GP FAX Number:
Tel No. (Home):
Tel No. (Work):
Mobile No.: / Referral Date:
Section A: Gynaecological Cancer type suspected
(Please put a X in appropriate boxes)
Ovary Cervix Endometrium Vagina Vulva
Investigations in Support of Referral
All referrals for suspected endometrial cancer (post-menopausal bleeding) must have a 2WW USS ordered on ICE (from SFH) at the same time as referring unless result already available
Pelvic ultrasound normal? / Y N / Ca125: Numerics
Section B: Signs/symptoms for 14 day rule criteria
(Please put a X in appropriate boxes)
B1. Lesion suspicious of cancer of cervix or vagina on speculum examination / Yes No
B2. Lesion suspicious of cancer on clinical examination of the vulva / Yes No
B3. Palpable pelvic mass not obvious fibroids / Yes No
B4. Suspicious pelvic mass on pelvic ultrasound / Yes No
B5. More than one or a single heavy episode of postmenopausal bleeding (PMB) in woman aged >55 who are not on HRT / Yes No
B6.Postcoital bleeding (PCB) age >35 years that persists for more than 4 weeks / Yes No
B7. HRT: Unexpected or prolonged bleeding persisting for more than 4 weeks after stopping HRT / Yes No
<Event Details>
Section C:Other information that you consider relevant about this patient
Section D: Other Investigations performed

Allergies:

Medication:

Acutes
Repeats

Minimum Dataset:

Blood Pressure
Weight
Smoking Status
Alcohol Intake
Carer Status
Investigations:(recordings in last 6months)

Blood Results:

FBC / Hb , WCC, Plts, MCV, Neut
UE / Na, K, Urea, Creat, eGFR
LFT / ALT, AlkPhos, Bili, Alb, GGT
CRP / ESR
TFTs / TSH, Free T4 / INR
Bone / Ca, Ca cor, Ca adj, Phos
Iron / Ferritin , Iron Saturation, TIBC
Vitamins / B12, Folate
Lipids / Chol, LDL, HDL,Chol:HDL ratio, Tri
Glucose / Glucose, Fasting / HbA1c