Two week referral for suspected head and neck cancer to plymouth hospitals trust for dental practitioner referrals only



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URGENT TWO WEEK REFERRAL FOR SUSPECTED HEAD AND NECK CANCER TO PLYMOUTH HOSPITALS TRUST

FOR DENTAL PRACTITIONER REFERRALS ONLY


If patient does not fulfil the criteria- please consider urgent/routine referral or treat/watch and wait approach.


PATIENT DETAILS


Surname:




Forename(s):




Date of Birth:




Age:




Male / Female:




NHS Number:




Address:


Postcode:




Telephone number:




Mobile number:





DENTIST DETAILS


Referring Dentist and address:



Registered GP:




Practice name/

address:


Postcode:




Telephone number:




Fax number:













Date of Referral:



Translator required Yes  No  If yes please contact GP Practice


Is patient aware of a possible Cancer diagnosis Yes  No 

RISK FACTORS

Yes No

Current Smoker  

Never Smoked  

Ex Smoker  

Tobacco Chewing Habit  

Heavy Alcohol Drinker  


PRIMARY SYMPTONS Please tick “” in applicable box
 Hoarseness for more than 4 weeks with a normal chest X-ray

 Dysphagia persisting >3 weeks

 Unilateral nasal obstruction particularly when associated with pleural discharge

 Unresolving neck mass for >3 weeks

 Cranial neuropathies

 Ulceration or oral mucosa persisting for >3 weeks

 Oral swelling persisting for >3 weeks

 All red patches of oral mucosa

 All red white patches of oral mucosa

 Unexplained tooth mobility (not associated with peridontal disease)

 Unresolved neck lumps for >3 weeks
PATIENT DETAILS


Surname:




Forename(s):




Date of Birth:




NHS number:




____________________________________________________________________________
SYSTEMATIC SYMPTONS
 Weight loss

 Symptoms of anaemia



 Other (please state - If details are not included under consultation notes, please attach on separate referral.)      
Additional clinical information including drug history: (please see information below or attach separately)
Consultation Notes (last 5 days):

CLINICAL INFORMATION SUMMARY


BMI:




BP:




Smoker:




Current Medication:






Repeat Medication:






Known drug allergies or adverse effects:







THIS FORM MUST BE FAXED TO (01752) 430912 – PLEASE TELEPHONE THE 2WW OFFICE ON (01752) 437506 TO ENSURE SAFE RECEIPT.

THIS IS FOR DENTAL PRACTITIONER REFERRALS ONLY




Version:

03/CAB/Microtest

Owner/Name:

Cancer Services

Date for Review:

March 2016








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