Northern Clinical Networks & Senate

GP DETAILS
GP Name
Practice name
Practice Address / Practice Code
Practice Tel. No
Fax No.
Date of Referral
PATIENT DETAILS
Forename
Surname
Previous Surname (if married)
Address
Post Code
Tel. No. Home
Tel. No. Mobile / DOB
Age
Sex
NHS No
Hospital No.
Patient previously visited this hospital?
Special needs / requirements? If yes, please state (e.g. Deaf, Hearing Loop, Wheelchair Access, Learning
Disabilities)
First language
If an interpreter is requiredplease specify language
Has the patient had any imaging/pathology relevant at another hospital/independent sector organisation?
YESNO
Please enclose results to avoid unnecessary delays.
Latest recorded smoking status:
Latest recorded alcohol consumption:
Is the Patient aware of the Urgent Referral for suspected malignancy: YESNO
Have you given your patient a 2 week wait leaflet? YESNO
Other Findings or Comments not included in Consultation above:
ENT REFERRAL
Patients with hoarseness persisting for more than 3 weeks with negative chest x-ray (but do not wait for the chest x-ray results) particularly smokers aged older than 50 and heavy drinkers
Upper dysphagia persisting > 3 weeks
Unexplained unilateral nasal obstruction when associated withblood-stained Discharge and/or unilateral facial swelling
PRESENTING
SYMPTOMS & SIGNS / EITHER ENT OR ORAL & MAXILLOFACIAL REFERRALS
Unexplained lump in the neck of recent onset, or a previously undiagnosed lump that has changed over a period of 3 to 6 weeks
Unexplained persistent swelling in the parotid or submandibular regions
Cranial neuropathies
Orbital masses
THYROID REFERRAL
Thyroid swellings associated with any of the follow:
Any solitary thyroid nodule, rapid increase in size of goitre or solitary thyroid nodule; history of neck irradiation; family history of an endocrine tumour; unexplained hoarseness or voice changes; cervical lymphadenopathy; patient aged >65.
ORAL & MAXILLOFACIAL REFERRAL
Ulceration of oral mucosa > 3 weeks
Oral swelling > 3 weeks
All red or red and white patches or oral mucosa
Unexplained tooth mobility (not associated with Peridontal disease)
RELEVANT INFORMATION
RELEVANT INFORMATION / THE LEVEL OF SUSPICION IS INCREASED IF THE PATIENT IS A HEAVY SMOKER OR HEAVY ALCOHOL DRINKER, MALE AND OVER 45 YEARS
Comments / other reasons for urgent referral:
Brief clinical history and site of lesion:
Relevant Past Medical History:
Medication / Drugs:
Allergies:

PLEASE FAX THIS FORM TO:

HOSPITAL OFFICE USE ONLY
Date of Referral Received
Number of Days between referral and Appointment Date
Appointment Date and Time

H&N & Thyroid NSSG 2014 (Final Version)