GP Proforma (Blank) Berkshire West / V 1.0 Blank
March 2016
If you need to use the diagram, please print the form and mark as appropriate and fax to RBH or, if attaching to an eReferral (formerly Choose & Book), you will need to print out, mark on diagram and scan into the patient record to attach
Contact details for the service
Organisation: / Royal Berkshire NHS Foundation Trust (RBH)
Patient’s details – patient must provide a current telephone number they can be contacted on between 08:00-17:00 /
GP details
Surname: / Referring clinician:Forename: /
GP address:
D.O.B.: / GP tel. no.:Sex: /
GP fax no.:
Title / GP email:Address: /
Date of referral:
NHS no.: / Essential Information (please attach)Hospital no.: / Current medication / allergies / current active problems and past medical history: / See below
Home tel.: / Agrees to message being left? Yes No
Work tel.: / Agrees to message being left? Yes No
Mobile tel.: / Agrees to message being left? Yes No / Typed referral letter attached (optional)? / Yes No
Email: / Discussions with patient prior to referral
Transport required? / Yes No / Is patient aware cancer is suspected? / Yes No
Language / hearing issues or interpreter required? / Yes No
If Yes, please specify: / Patient given urgent referral information sheet? / Yes No
Learning difficulties? / Yes No / Dates unavailable in next 14 days?
Mental capacity assessment required? / Yes No
Known safeguarding concerns? / Yes No
Performance status:
(0 = no impairment, 4 = severe) / <Select>01234
BASAL CELL CARCINOMA: routine referral unless particular concern that delay may have significant impact because of site/size (high risk, i.e. near a sensitive site such as eye, nostril, in the pinna; or is a large size >2 cm)
SYMPTOMS & CLINICAL EXAMINATIONS / SITE AND SIZE, PLEASE MARK ON DIAGRAM
Type of suspected cancer: /
High risk BCC (see above)
Skin lesion raises suspicion of squamous cell carcinoma
Clinical features / dermoscopy suggests malignant melanoma
Major features
(2 points each) / Minor features
(1 point each)
change in size / Largest diameter =>7mm
irregular shape / inflammation / /
irregular colour / oozing
change in sensation
Total score:
Other (please specify why 2WW referral needed):
Please state why you think this is a skin cancer - include symptoms, duration, risk factors, clinical & dermoscopic signs (this information is mandatory, referral will be returned if field left blank):
NHS SCW CSU / IT Training Team / EBR Page 1 of 2
NAME: NHS NUMBER: D.O.B.:
MEDICAL HISTORY
Current medication
Allergies / adverse reactions
Past medical history
NHS SCW CSU / IT Training Team / EBR Page 2 of 2