REFERRAL – 2WW HAEMATOLOGY

From:

Address:
Post code:
Date of Referral: / GP’s name:
PCT code:
Tel no:
Fax no:
Patient Details:
Name:
Address
Post code:
Has patient previously visited this hospital? Yes / D.O.B: Age:
Gender:
Tel no (home):
Tel no (mobile):
New NHS No:
First Language:
Interpreter required? Yes

Referral information (please check boxes):

Malignancy suspected:Leukaemia Lymphoma (HD or NHL) Myeloma
Symptoms:
Night sweats Yes No / Breathlessness Yes No
Weight loss Yes No / Bruising Yes No
Itching Yes No / Recurrent infections Yes No
Fatigue Yes No / Bone pain Yes No
Clinical examination: / Pallor Yes No
Lymph nodes - neck Yes No / Hepatomegaly Yes No
- axilla Yes No / Splenomegaly Yes No
- groin Yes No / Bruising / petechia Yes No
- other Yes No / Stomatis / mouth ulcers Yes No
Investigations:
Chest X-ray
Others
General Health:
Comments/other reasons for urgent referral:
Signed:-
[Name of Referring GP]

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