2WW SUSPECTED LUNG CANCER REFERRAL FORM (V5)

FAX No: 01522 573351

PATIENT: / REFERRING PRACTITIONER:
Surname: / Mr Mrs Miss Ms / GP Name:
Address:
First Name:
Address:
Post Code:
Date of Birth dd/mm/yyyy: / Age:
Telephone No (Home): / Mobile Tel No:
Telephone No (Daytime): / E-Mail:
GP Telephone No:
NHS Number: / Hospital No: / Safe Haven Fax No:
Date Decision to refer: / Date of referral:

RELEVANT HISTORY(please tick/click the correct box)

Presenting symptoms / /
Yes
/
No
Haemoptysis in a smoker or ex-smoker over 40 years of age.
Signs of Superior vena caval obstruction (swelling of face/neck with fixed elevation of JVP)
Persistent or recurrent chest infection in a smoker
Altered or severe cough in a COPD patient
Cervical LN’s
Stridor (consider an emergency admission)
Chest X-Ray:
Suggestive/suspicious of Lung Cancer (including pleural effusion and slowly resolving consolidation)

NB: Any patient with a persistent cough or chest symptoms, especially if a smoker over the age of 40 should be referred early for CXR.

IMPORTANT PATIENT FACTORS

/
YES
/
NO
Place CXR done: / a)Lincoln Hospital / Date:
b)Pilgrim Hospital / Date:
c)Grantham & District Hospital / Date:
d)Louth Hospital / Date:
e)Other (please state): / Date:
Does the patient have diabetes?
Does the patient have renal failure?
Has patient been told of suspicion of cancer?
Is the patient known to have MRSA?
What is the patient’s exercise tolerance? / e.g. metres:
Please tick box to indicate if the patient is taking any of the following: / Aspirin / Clopidogrel / Warfarin
Comments/Concomitant disease/Reasons to support 2 Week Wait Referral:

Signed:……………………………………………

ACTION: Please send electronically or fax the form to the dedicated 2-week wait fax line – Please ensure you identify the patients preferred hospital by ticking/clicking the appropriate box:

Has the patient given consent to telephone contact?:

/

Yes

/ /

No

/
Preferred Hospital for Patient / /

GranthamDistrictHospital

/ /

PilgrimHospital, Boston

/

LincolnCountyHospital

/ /

LouthHospital

/

JohnCouplandHospital, Gainsborough

2 WEEK WAIT PATIENTS WILL BE “FAST TRACKED” THROUGH THE SYSTEM. WE WOULD WELCOME A REFERRAL LETTER TO BE FAXED WITH THIS FORM GIVING ANY OTHER RELEVANT INFORMATION