Gp Referral Proforma For

2WW

GP REFERRAL PROFORMA FOR ONE STOP BREAST CLINIC

PLEASE ATTACH ELECTRONICALLY TO CHOOSE & BOOK REFERRAL
On completion please attach to Choose & Book Referral. Please contact the number below if CAB unavailable
Decision to refer date: UBRN:
Is patient aware that this is a suspected cancer referral? Yes No
If No, please state reasons why:
Has patient information leaflet been issued? Yes No
If No, please state reasons why:
Does the patient have availability within the next 14 days? Yes No
Please state any days which the patient is NOT available within the next two weeks:
Patient Details:
Surname: «PATIENT_Surname»
Forename: «PATIENT_Forename1»
Address: «PATIENT_House» «PATIENT_Road»
«PATIENT_Locality»
«PATIENT_Town»
«PATIENT_Postcode»
DOB: «PATIENT_Date_of_Birth»
Hosp No: «REFERRAL_Hospital_number»
NHS No: «PATIENT_New_Format_NHS_Number»
Contact Tel No: «PATIENT_Main_Comm_No» / Referring GP Details:
Name: «REFERRAL_Clinician»
Practice: «PRACTICE_Name»
«PRACTICE_House»
«PRACTICE_Road»
«PRACTICE_Locality»
«PRACTICE_Town»
«PRACTICE_County»
«PRACTICE_Postcode»
Telephone No: «PRACTICE_Main_Comm_No»
Fax No: 01275 891637
Mammogram in last 3 years? Yes No
Location:
Date: / Re-Referral? Yes No
Date Last Referred:
Family history of breast cancer? Yes No
If yes please specify:
Note to Referring GP: As part of the one stop assessment clinic, suitable patients would normally undergo mammography as part of the assessment. By making this referral you agree for the patient to undergo mammography. It is therefore imperative that the following information is completed failure to do so will result in referral being returned:
Is there a possibility of pregnancy: Yes No Date of LMP:
SUSPECTED CANCER
(In line with NICE Guidelines 2005)
Patients must present with one or more of the following symptoms (please tick all that apply):
Any age with a discrete, hard lump with fixation, with or without skin tethering.
Females aged 30 years and older with a discrete lump that persists after their next period, or presents after menopause
Females aged younger than 30 years:
with a lump that enlarges
with a lump that is fixed and hard
in whom there are other reasons for concern such as family history (please specify in additional information)
of any age, with previous breast cancer, who
present with a further lump or suspicious symptoms
with unilateral eczematous skin or nipple change that does not respond to topical treatment
with nipple distortion of recent onset
with spontaneous unilateral bloody nipple discharge
males aged 50 years and older with a unilateral, firm subareaolar mass with or without nipple distortion or associated skin changes / FOR REVIEW BUT NOT SUSPECTED CANCER
Patients should meet one or more of the following criteria:
Women aged younger than 30 years with a lump such as a suspected fibroadenoma
Patients with breast pain and no palpable abnormality, when initial treatment fails and/or with unexplained persistent symptoms
menopausal woman with unilateral pain
abscess or recurrent cyst
long standing nipple retraction
Please indicate location of lump:
Left Right
LUMP size: cms
Any other referral reason?

Significant past medical history, present medication and allergies will be included automatically: Please enter below any other significant additional information or attach relevant results/documentation to the UBRN in Choose & Book.

Patient Details:
Surname: «PATIENT_Surname»
Forename: «PATIENT_Forename1»
Hosp No: «REFERRAL_Hospital_number»
NHS No: «PATIENT_New_Format_NHS_Number»

Past Medical History:

«MEDICAL_HISTORY»

«PROBLEMS»

Medication:

«REPEATS»

Allergies:

«DRUG_ALLERGY»

Should the Choose and Book system become unavailable, please contact your local CAB Lead.
Bristol / 0117 9841602

Refer to:

UHB

NBT
Weston

Page 1 of 3 BNSSG One Stop Breast Referral Vision

Last saved on Wednesday, 15 July 2009