Priority
Referral Date:
Short date letter merged 	

	Priority:
Suspected Cancer Referral	

	NHS Number:
NHS Number 	

Patient Details / Contact Information
Title:
Title 	

	Forename:
Given Name 	

	Surname:
Surname 	

Date of Birth:
Date of Birth 	

	Gender:
Gender(full) 	

	Ethnicity:
Ethnic Origin 	

Address:
Home Full Address (stacked) 	

	Home Telephone Number:
Patient Home Telephone 	

	Email:
Patient E-mail Address 	

	OR Mobile Telephone Number:
Patient Mobile Telephone 	

	Text Message Consent:
Yes          No 	

Preferred Contact Time:
     	

Referrer / Practice Details
Referring Name:
Current User      	

	Referrer Code:
     	

	Practice Code:
Registered GP Organisation National Practice Code 	

Registered GP:
Registered GP Full Name 	

	Surgery Name:
Registered GP Organisation Name 	

	Surgery Address:
Registered GP Full Address (stacked) 	

Surgery Telephone Number:
Organisation Telephone Number	

	Generic Surgery Email Address:
Organisation E-mail Address 	

Mandatory Information – will be returned if not complete
Most patients will have investigations prior to having an appointment or during their first hospital visit. It is therefore important that patients are prepared for this and aware of the reason for their referral. Please ensure the mandatory information below is provided and all relevant investigations are completed and attached. 
		Yes	No	
1.	Has the patient been informed they are on a suspected cancer pathway, given appropriate support and advised they need to be available at any time within the next two weeks?		

	
	If no, please explain why: 	     	

2.	Have you ensured that the telephone contact details are correct?		

	
	Landline Number:	     	

	OR Mobile Number:	     	

3.	Have you told your patient they may have appointments and tests arranged at any hospital across Greater Manchester?	    

	

	
4.	Accurate functional status is needed to assess the most appropriate investigation and treatment.
Please select a score from one of the following  and enter in the score field:	

Score:
     	

	Rockwood Score 1-3	Managing Well.  Not limited by any comorbidities		
	Rockwood Score 4	Vulnerable, not dependant, symptoms limit activities		
	Rockwood Score 5	Mildly frail, evident slowing, need help with daily activities		
	Rockwood Score 6	Moderately frail, need help with all outside activities and bathing		
	Rockwood Score 7-8	Severely frail, completely dependent for personal care		
	Rockwood Score 9	Terminally ill, life expectancy of <6 months		
5.	Are there any concerns about this patient’s capability to consent to investigation/treatment?		

	
	If Yes, has the next of kin/advocate been asked to attend?		

	
6.	Is the patient taking anti-coagulants?		

	
	If Yes please give details:	     	

7.	Is the patient diabetic and taking Metformin?
If Yes please give details: 
     	

		

8.	Current eGFR of patient: 

Recent changes to guidance mean eGFR is no longer required in all patients

If the value is not appearing this has not been recorded in the last 3 months, has the eGFR been requested today in patients: 

• with known renal disease (CKD3/4/5 or renal transplant)
• who are diabetic
• on metformin
	Value:
Single Code Entry: Glomerular filtration rate...	

		Yes	No	

		

9.	Does the patient require Translation or Interpretation Services?		

	
	If Yes, which language:	     	

10.	Please list any other impairments requiring specialist help for example deaf or blind:
     	

Referral Reason (include relevant family history and previous history of cancer)

	

SYMPTOMS INCLUDE:	Yes	No	
•		Weight loss – please indicate how much weight and what length of time:
     	

		

•		Decreased appetite		

	
•		Nausea		

	
•		Bloating 		

	
•		Abdominal pain – non specific		

	
•		Persistent pain		

	
•		Other pain (please specify) 
     	

		

•		Fatigue		

	
•		Anaemia		

	
•		Unexplained night sweats		

	
•		Lymphadenopathy		

	
	•		Inguinal – refer RDC		
	•		Axillary – refer Breast Clinic		
	•		Cervical – refer neck lump clinic using Head and Neck Suspected Cancer Referral form		
•		Hepatomegaly		

	
•		Splenomegaly		

	
•		Unprovoked DVT with signs and symptoms suggesting underlying cancer		

	
•		Abnormal imaging suggestive of metastatic disease (please attach report)		

	
•		GP concern (please include in referral reason above) 		

	
•		Continued patient of family concern (please include in referral reason above)		

	

EXCLUSION CRITERIA:	Yes	No	
Has the patient had any of the following? (if so please manage in accordance with the specific guidelines in NICE NG12)	
•		Haematuria		

	
•		Post-menopausal bleeding		

	
•		Abnormal vaginal bleeding		

	
•		Haemoptysis		

	
•		Cough		

	
•		Melaena		

	
•		Rectal bleeding		

	
•		Hematemesis		

	
•		Dysphagia		

	

Please consider doing the following investigations where clinically appropriate: 
	Yes	No	
Please include reports of all other recent investigations e.g. ultrasound / CT/ MRI / Gastroscopy	
•		Full Blood Count		

	
•		Liver Function		

	
•		Renal Function		

	
•		PV/CRP		

	
•		Ferritin		

	
•		Coeliac Screening		

	
•		Bone Profile (including Calcium)		

	
•		HbA1c		

	
•		FIT Test 		

	
•		Urinalysis		

	
•		Thyroid Function Test		

	
•		Myeloma Screen		

	
•		Glandular Fever Screen			

	
•		HIV Screen		

	
•		CA125 (female only)		

	
•		PSA (male only)		

	

Additional Information
     	

Smoking 
Consultations 

Pathology
Sodium	Single Code Entry: Serum sodium level  	Total Chol.	Single Code Entry: Serum total cholesterol level  	WCC	Single Code Entry: Total white cell count...  	
Potassium	Single Code Entry: Serum potassium level  	LDL Chol.	Single Code Entry: Serum low density lipoprotein cholesterol level  	Plat	Single Code Entry: Platelet count...  	
Urea	Single Code Entry: Serum urea level  	HDL Chol.	Single Code Entry: Serum high density lipoprotein cholesterol level  	MCV	Single Code Entry: MCV - Mean corpuscular volume...  	
Creatinine	Single Code Entry: Serum creatinine level...  	Folate	Single Code Entry: Serum folate level  	Ferritin	Single Code Entry: Serum ferritin level  	
eGFR	Single Code Entry: Glomerular filtration rate...	Bilirubin	Single Code Entry: Serum bilirubin level  		

Haematology
Haemoglobin:		Haemoglobin 
Haemoglobin estimation:	Single Code Entry: Haemoglobin estimation
ALT:			ALT 
Blood Glucose:		Blood Glucose 
Alkaline Phosphatase:	Alkaline Phosphatase 
Radiology:		Radiology 

Diabetic Control
Please indicate if patient is stable and what management has been attempted:
     	
HbA1c:		HbA1c

Thyroid Function (if applicable)
T4 / TSH Test (to ensure this is not repeated unnecessarily in secondary care)	
T4:		Single Code Entry: Serum free T4 level    
	TSH:		Single Code Entry: Serum TSH (thyroid stimulating hormone) level	

Health Profile
Problems 
Medication 
Allergies 
Family History 
Alcohol Consumption 
Weight 
Height 
BMI 

Last 5 Bps
Blood Pressure 

Long Term Conditions
IHD:		Single Code Entry: Aortocoronary artery bypass graft repeated...  
Diabetes:	Single Code Entry: Diabetes mellitus without complication...  
 		Single Code Entry: Diabetes mellitus type 1 with ketoacidotic coma...  	
Hypertension:	Single Code Entry: Hypertensive disease...  
Epilepsy:	Single Code Entry: Recurrent complex partial epilepsy...
Stroke/TIA:	Single Code Entry: Anterior cerebral artery syndrome...  
Parkinson’s:	Single Code Entry: Parkinson's disease...  
Dementia:	Single Code Entry: Circumscribed cerebral atrophy...  

COPD:		Single Code Entry: Acute vesicular emphysema...  
CKD:		Single Code Entry: Chronic kidney disease stage 4...  
Neoplasms:	Single Code Entry: [X]Additional neoplasm classification terms...  
		Single Code Entry: Neuroblastoma of central nervous system...  		

Contraception 
FOR FEMALE PATIENTS ONLY
(please check medication screen for items that may not have filtered through)
     	
Single Code Entry: Prescribed postcoital oral contraceptive pill...  

Please send completed forms via e-referral, e.g.

	
Service ID 
 
2WW Rapid Diagnostic Centre - Referral Assessment Service*Site name to be added as applicable	
 Service 
 Name