Urgent 2 Week Wait Referral for Suspected Colorectal Cancer
Urgent 2 Week Wait Referral for Suspected Colorectal Cancer
Preferred site: North Tyneside Wansbeck General Hexham General
Please Fax. Referral within 24hrs to: 0191 2934107
Section 1 PATIENT INFORMATION (Please complete in BLOCK CAPITALS)SurnameSurname
First name Forename
Title Title / Date of ReferralTodays date
NHS NumberNHS number
Gender Gender / Age Patient Age
Home Tel.Patient home telephone number
Address: Patient address housePatient address road,
Patient address locality,
Patient address post town,
Patient address county,
Post CodePatient post code / Mobile / Daytime Tel: Patient mobile telephone number/
Transport Y N / Interpreter Y N
UBRN - -
Section 2 PRACTICE INFORMATION (Please use practice stamp if available)
Referring GP Sender title and surname / LocumY N
Practice Address
Sender organisation name
Sender address / Telephone Sender telephone number
Fax Sender fax
Practice codeRegistered GP practice ID
Section 3 CLINICAL INFORMATION (Please TICK all applicable entries)
Please enclose printouts of CURRENT medications and PAST MEDICAL HISTORY
All ages
Definite, palpable, right sided, abdominal
mass
Definite, palpable, rectal (not pelvic) mass / Over 40 years
Rectal bleeding WITH a change of bowel habit towards looser stools
&/or increased frequency 6 wks
Over 60 years
Rectal bleeding persisting 6 wks WITHOUT a change in
bowel habit or anal symptoms (eg soreness, discomfort, itching, prolapse, pain)
Change in bowel habit to looser stools &/or more frequent stools
persisting 6 wks WITHOUT rectal bleeding
Medical History, Known Allergies (see attached)
DIABETIC:Y N / All Medication
WARFARIN:Y N
CLOPIDOGREL:Y N / Investigations
PR examinationY N
Abdo examinationY N
Findings:
FBC:
Hb:
MCV:
Family Historyincl. relative and age at diagnosis / Fitness Rating (ECOG)
SELECT FITNESS RATING0 Fully active1 Unable to do stren.activity-mainly conf to chair2 Able to walk and self-care3 Able to carry out limited self-care4 Completely confined to bed/chair
Discussed urgent suspected cancer referral with patient:Y N
Your patient may go straight to a diagnostic test, for example, Colonoscopy, Flexi sigmoidoscopy, CT abdo pelvis.
• In your opinion would this patient be suitable to go straight to a diagnostic test? Yes No
• Have you told the patient they may go straight to a diagnostic test? Yes No
Comments:
NHS NumberNHS number,Surname Surname, First name Forename
Active Problems
Active Problems (w/o contents)
Medication
Current Issues
Allergies
Allergies