Lung cancer referral form.doc

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					                                  North London Cancer Network
                                    Suspected Lung Cancer Referral Form
To make a referral, FAX this form to the relevant Hospital. You may also fax an accompanying letter / print out if you wish to do so.

 DATE OF REFERRAL:
 Please the corresponding box for the hospital the referral is being made to:
 Barnet                       Chase Farm                           North Middlesex                    PAH
 Fax: 020 8216 4175           Fax: 020 8375 1977                   Fax: 020 8887 2663/4               Fax: 01279 827 171
 Tel: 020 8216 4322           Tel: 020 8370 9079                   Tel: 020 8887 2661/2               Tel: 01279 827 550
 Royal Free                   UCLH                                 Whittington
 Fax: 020 7830 2986           Fax: 020 7380 9932                   Fax: 020 7288 5621
 Tel: 020 7830 2143           Tel: 020 7380 9599                   Tel: 020 7288 5511/12

 The PATIENT                                                       REFERRAL INFORMATION must be completed
 SURNAME:                                                          New symptoms                                           Y     N
                                                                   Urgent Chest X-ray should be done
 FIRST NAME:
                                                                   CHEST XRAY Fax report with this form                   Y     N
 ADDRESS:                                                          Date……………………………………………
                                                                   Where…………………………………………
                                                                   Abnormal suspicious of cancer                          
                                                                   Abnormal other                                         

 DOB                                             Male/Female       History of COPD                                        Y     N
 TEL No:                                                           Current Smoker                                         Y     N
 WORK NO:                                                          Ex-Smoker                                              Y     N
 MOBILE NO:
                                                                   SYMPTOMS:
 NHS NO (required):                                                Persistent Haemoptysis in smoker or ex smoker >40 years
 Has the patient previously visited the hospital?         Y/N      None                                            
 Hospital No:                                                      Once                                            
                                                                   >1                                              
 Is an interpreter required? If yes, which language
                                                                   Unexplained or persistent symptoms (>3weeks):
 Is transport required?                                   Y/N      Cough                                                  Y     N
                                                                   Wheeze                                                 Y     N
 Family History:                                                   Weight Loss                                            Y     N
                                                                   Breathlessness                                         Y     N
                                                                   Chest/shoulder pain                                    Y     N
 Medical History:                                                  Hoarseness                                             Y     N
                                                                   Chest signs                                            Y     N
                                                                   Finger clubbing                                        Y     N
                                                                   Lymphadenopathy cervical or supraclavicular
                                                                   or features of metastasis from lung cancer             Y     N
 Medication:

                                                                   Information given to Patient



 The REFFERING GP:
 NAME:

 ADDRESS:



 TEL NO:
 FAX NO:
 GP SIGNATURE:



                                                                                                              Final Version 01.11.05
                                     Lung cancer

       Patient presents with




                                      Patients presenting
Any of the following:                 with the listed
                                                                Persistent
 haemoptysis                         symptoms or signs
                                                                haemoptysis           Superior
 unexplained persistent (over 3      AND the following
                                                                in smokers             vena caval
  weeks):                             risk factors:
                                                                or ex-                 obstruction
    chest/shoulder pain                    current or
                                                                smokers who           Stridor
                                                ex-smoker
    dyspnoea                                                   are 40 years
                                            COPD
    weight loss                                                or older
                                            exposure to
    chest signs
                                                asbestos
    hoarseness
                                            history of
    finger clubbing
                                                cancer
    cervical/supraclavicular                   (especially
        lymphadenopathy                         head and
    cough with or without any                  neck).
        of the above                  may be referred
    features suggestive of           earlier for chest x-ray
        metastasis from lung          or to a specialist
        cancer.




                                   Suggestive of lung
                                   cancer including:
                                       Slowly resolving
   Chest X-ray                             consolidation
   (report back in 5 days)             pleural effusion.




     Normal but referring
     doctor has high
     suspicion of cancer


   Urgent referral                                                             Consider
                                                                               immediate referral




                                                                                  Final Version 01.11.05

				
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