Referral Date:	Priority:	NHS Number:	
Short date letter merged 	Referral Urgency      	NHS Number	
Priority

Patient Details / Contact Information
Title:	Forename:	Surname:	
Title 	Given Name 	Surname 	
Date of Birth:	Gender:	Ethnicity:	
Date of Birth 	Gender(full) 	Ethnic Origin      	
Address:
	Home Telephone Number:	Email:	
Home Full Address (stacked) 	   Patient Home Telephone      	  Patient E-mail Address      	
	 OR Mobile Telephone Number:	Text Message Consent:	
	   Patient Mobile Telephone      	   Yes                  No  	
Preferred Contact Time:	Interpreter Required: 	Preferred Language: 	
     	Yes                  No  		
Referrer / Practice Details
Referring Name:	Referrer Code:	Practice Code:	
     	     	Registered GP Organisation National Practice Code 	
Registered GP:	Surgery Name:	Surgery Address:	
Registered GP Full Name      	Registered GP Organisation Name 	Registered GP Organisation Full Address (single line) 

Surgery Telephone Number:
	  Generic Surgery Email Address:		
Registered GP Phone Number 	   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 dependent, 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 capacity 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 etc. 	
	       	

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

	

Referral Information

PROSTATE CANCER
Patient information leaflet
https://itservices.midlandsandlancashirecsu.nhs.uk/media/1137/prostate_btp_patient_info_leaflet_041219.pdf

Ensure that all available PSA values are included in this referral.
Consider the impact of referring patients with significant co-morbidity and the very frail elderly as referral may not be appropriate. If in doubt, consult your local specialist.

•	Hard irregular prostate on DRE (please specify side)

•	Raised age-related PSA UTI having been excluded 	
	
LEFT

YES

	
	
RIGHT

NO

	

Information regarding PSA testing:

	•	PSA can be markedly raised in a UTI and should avoided in this scenario							
	•	If there are any sign of advanced or metastatic prostate cancer a two week wait referral is still indicated irrespective of a UTI.							
	•	Following a UTI it can take up to six weeks or more for the PSA to normalise

	•	Rectal examination and exercise have minimal effect on PSA and should not affect the timing of testing
•	Ejaculation only has a minor impact on PSA results but it is best avoided for 48 hours

Age related cut-off measurements for PSA:

<49 years: refer if PSA level is 2.0 nanogram/mL or higher
50−59 years: refer if PSA level is 3.0 nanogram/mL or higher 
60−69 years: refer if PSA level is 4.0 nanogram/mL or higher 
70−74 years: refer if PSA level is 5.0 nanogram/mL or higher 
75−80 years: refer if PSA level is 7.5 nanogram/ml or higher
>80 years: Men aged 80 years and over can be referred for assessment but there is no stipulated range to necessarily trigger a
2 week wait other than Clinician discretion.

NHSE is considering reviewing PSA referral criteria. Currently the GM Cancer Alliance is using the age specific PSA levels above.	

PSA Results: Prostate Specific Antigen:        Prostate 

BLADDER AND RENAL CANCER (age 45 and above)
                                                                                                                                                               YES           NO
§	Unexplained visible haematuria and no UTI						
§	Visible haematuria that persists or recurs after successful treatment of UTI						

BLADDER CANCER (age 60 and above)
                                                                                                                                                                    YES            NO
§	Unexplained non-visible haematuria PLUS either:					
	•	Dysuria					
	•	Raised white cell count on blood test					

TESTICULAR CANCER
                                                                                                                                                                    YES            NO
	•	Non painful enlargement or change in shape or texture of testis 					
	•	Suspected testicular cancer on USS report (report attached)					

PENILE CANCER
                                                                                                                                                                    YES            NO
	•	Penile mass or ulcerated lesion where STD is thought to be unlikely or excluded as cause					
	•	A penile mass or ulcerated lesion persisting after treatment of STD					
	•	Unexplained or persistent symptoms affecting foreskin or glans					

HAEMATURIA
                                                                                                                                                                               
	•	Refer patients under 45 with visible haematuria for non-urgent investigation. 	
	•	Refer patients with persistent non-visible haematuria for non-urgent investigation	
	•	Consider prostate cancer via DRE and PSA.	

Additional Information

     	

Smoking 
Consultations 

Consultations
Consultations

Pathology 
Sodium: 	Single Code Entry: Serum sodium 
Potassium:	Single Code Entry: Serum potassium 
Total Chol:         	Single Code Entry: Serum total cholesterol level 
LDL Chol:            	Single Code Entry: Serum LDL cholesterol level 
HDL Chol:           	Single Code Entry: Serum HDL cholesterol level 
WCC:                   	Single Code Entry: Total white cell count 
Platelet Count: 	Single Code Entry: Platelet count 
MCV:                  	Single Code Entry: Mean corpuscular volume (MCV) 
Urea:                  	Single Code Entry: Serum urea level 
Creatinine:       	Single Code Entry: Serum creatinine 
eGFR:                 	Single Code Entry: Glomerular filtration rate... 
Bilirubin Level: 	Single Code Entry: Serum bilirubin level 
Folate:               	Single Code Entry: Blood folate 
Ferritin:             	Single Code Entry: Serum ferritin

HAEMOTOLOGY
Haemoglobin: 		Haemoglobin
ALT: 			ALT
Blood Glucose:		Blood Glucose  
Alkaline Phosphatase:	Alkaline Phosphatase 

RADIOLOGY
Radiology

DIABETIC CONTROL 
HbA1c: 		 Single Code Entry: Haemoglobin A1c level – IFCC standardised 

THYROID FUNCTION
T4: 		Single Code Entry: Serum free T4 level
TSH: 		Single Code Entry: Serum TSH level  

HEALTH PROFILE
Problems 
Medication 
Allergies 
Family History 
Alcohol Consumption 
Smoking 
Weight 
Height 
BMI 
Blood Pressure 

Long Term Conditions 
IHD: 		Single Code Entry: Ischaemic heart disease 
Diabetes: 	Single Code Entry: Diabetes mellitus... 
Hypertension: 	Single Code Entry: Essential hypertension 
Epilepsy: 	Single Code Entry: Epilepsy 
Stroke/TIA: 	Single Code Entry: Cerebrovascular disease 
Parkinson’s:	Single Code Entry: Parkinson's disease 
Dementia: 	Single Code Entry: Senile dementia... 
COPD: 		Single Code Entry: Chronic obstructive pulmonary disease 
CKD: 		Single Code Entry: Chronic kidney disease stage 1 with proteinuria... 
Neoplasms: 	Single Code Entry: Neoplasms

Contraception (please check medication screen for items that may not have filtered through)
Single Code Entry: Prescribed post-coital OCP