HANS Referral Form
Patient details
Surname:Click here to enter text.
First name: Click here to enter text.
Address:Click here to enter text.
Mobile phone no: Click here to enter text.
Home no: Click here to enter text.
NHS no:Click here to enter text.
Date of birth:Click here to enter text.
Referring Clinician details
Name:Click here to enter text.
Hospital:Click here to enter text.
Address:Click here to enter text.
Contact number:Click here to enter text.
Email address:Click here to enter text.
GP surgery details
Name:Click here to enter text.
Address:Click here to enter text.
Contact number:Click here to enter text.
email address: Click here to enter text.
Referral details
Urgent (to be seen within 2weeks) : ☐
Routine (To be seen within 8 weeks): ☐
Reason for referral: Click here to enter text.
Date of referral:Click here to enter a date.
If previous diagnosis of cancer, details of cancer clinician in charge:
Click here to enter text.
Will the clinician be continuing follow up of the primary cancer? ☐
Medical history (A):
Previous ano-genital cancer☐
anal canal☐perianal area☐
vulva☐ vagina ☐
cervix ☐ penis☐
other☐
WhenClick here to enter text.
StageClick here to enter text.
Treatment:
Chemo-radiotherapy ☐ Radiotherapy☐
Surgical excision☐ Laser ablation ☐
Other☐
Previous pre-cancer☐
anal canal ☐ perianal area ☐
vulva ☐vagina ☐
cervix☐ penis☐
other☐
WhenClick here to enter text.
Stage (Eg: AIN2, AIN3 etc) Click here to enter text.
Treatment:
Topical ☐ Laser ablation ☐
surgical excision☐ other☐
Medical history (B):
Immune-defect
Innate☐
HIV Name of HIV doctor Click here to enter text.
Current CD4 count Click here to enter text.
VL Click here to enter text.Date Click here to enter text.
CD4 nadir Click here to enter text.DateClick here to enter text.
ARV Y☐ N☐ started date Click here to enter text.
AIDS DX Y☐ N ☐ yearClick here to enter text.
Transplant ☐type: Click here to enter text. Year Click here to enter text.
Immunosuppression drugs: ☐
If yes, please write name and doses:
Click here to enter text.
Other ☐
Please describe: Click here to enter text.
Medical history( C):
Current medications with doses
Click here to enter text.
Allergy
Click here to enter text.
Vaccination ☐
GARDASIL ☐
CERVARIX ☐
GARDASIL 9☐
Date of 1st dose Click here to enter text.
Date of last doseClick here to enter text.
Please email the completed form securely to: