REFERRAL 2WW HEAD and NECK

From:
Address:

Referring GPs name:

Please type in free text if not imported:
P.C.T. code:
Tel no:
Fax:

Post code:
Date of Referral:
Patient Details:
Name:
Address

D.O.B:
Age:
Gender:
Tel no (home):
Tel no (work):
New NHS No:
First language:
Interpreter required? Yes

Post code:
Has patient previously visited this hospital?
Yes
No

No

Referral information (please check boxes):

Cancer Area Suspected:
Oral cavity
Pharynx
Thyroid

Yes
Yes
Yes

No
No
No

Larynx

Risk factors:
Poor Diet
Alcohol

Yes
Yes

No
No

Smoker

Yes

No

Symptoms:
Pain on swallowing
Deafness
Sore throat
Hoarseness

Yes
Yes
Yes
Yes

No
No
No
No

Dysphagia
Nasal obstruction/discharge
Otalgia
Bleeding

Yes
Yes
Yes
Yes

No
No
No
No

Clinical Examination:
Oral ulceration/tumour
Lump in neck
Thyroid lump

Yes
Yes
Yes

No
No
No

Orbital mass
Other

Yes

No

General Health:

Comments/other reasons for urgent referral:

Signed:-
[Name of Referring GP]

Other

Yes

No

Past Medical History

Problems

Drugs

Allergies

To be completed by the Data Team:

Date received:..........................................Date 1st appointment booked:. .............................................
Date of 1st appointment: ...................................
Date 1st seen: .....................................................
Specify reason if not seen at 1st appointment offered:.........................................................................................
Final diagnosis:

Malignant
Benign