BNSSG Suspected head and neck Cancer Referral Form
All referrals should be sent via e-RS with this form attached within 24 hours 
DENTISTS – please email referral to FastTrackOffice@uhbw.nhs.uk
Please ensure all fields are completed, this will help ensure the patient is seen in the most appropriate clinic and in a timely way.  Requesting additional information can delay appointments.

1.	REFERRER DETAILS – ESSENTIAL	
Usual GP name: Usual GP Full Name	Referring clinician: Free Text Prompt	
Practice code: Organisation National Practice Code      	Practice address: Organisation Full Address (stacked) 	
Practice name: Organisation Name 	Email: Organisation E-mail Address 	
Main Tel: Organisation Telephone Number 	Practice bypass number       (manual entry)	

2.	PATIENT DETAILS – ESSENTIAL	
Surname:  Surname 	First name: Given Name 	
NHS number: NHS Number 	Title: Title 	
Gender on NHS record: Gender(full) 	Gender Identity:       (manual entry)	
Ethnicity:      	Hospital No.: Hospital Number      	
DOB: Date of Birth 	Age:      	
Patient address: Home Full Address (stacked) 	
Daytime contact Tel:       Home: Patient Home Telephone  Mobile: Patient Mobile Telephone  
Please check telephone numbers	
Email:      	
Does the patient have the capacity to consent? Yes    No   	
	
Carer/ key worker details:	
Name:         	Contact Tel:        	
Relationship to patient:      		

3.	REASON FOR REFERRAL – ESSENTIAL
See Remedy Head and Neck Cancer Referral Guidance	
Please record below the history and findings on physical examination and why you feel the patient may have cancer:
     

	
4.	SPECIFIC CRITERIA FOR URGENT REFERRAL – ESSENTIAL	
 Criteria for urgent SUSPECTED HEAD AND NECK CANCER – NECK LUMP:	
 An unexplained palpable lump in the neck i.e. of recent onset or a previously undiagnosed lump that has changed over a period of 3 – 6 weeks.
 An unexplained persistent swelling in the parotid or submandibular gland	
Criteria for urgent SUSPECTED THYROID CANCER:	
 Unexplained thyroid lump 
Please perform thyroid function test in parallel with referral	
 Criteria for urgent SUSPECTED HEAD AND NECK CANCER – EAR, NOSE AND THROAT ORIGIN:	
 Persistent unexplained hoarseness i.e. >3 weeks, with negative chest X-ray 
 An unexplained persistent sore throat especially if associated with dysphagia, hoarseness or otalgia 
 Persistent unilateral nasal obstruction with bloody discharge 
 Unexplained unilateral serous otitis media/ effusion in a patient aged over 18	
 Criteria for urgent SUSPECTED HEAD AND NECK CANCER – ORAL MAXILLO-FACIAL ORIGIN	
 Unexplained ulceration of the oral cavity or mass persisting for > 3 weeks 
 Unexplained red and white patches (including suspected lichen planus) of the oral cavity particularly if painful, bleeding or swollen 
 Oral cavity and lip lesions or persistent symptoms of the oral cavity followed up for six weeks where definitive diagnosis of a benign lesion cannot be made 
 Non-healing extraction sockets (>4 weeks duration) or suspicious loosening of teeth, where malignancy is suspected (particularly if associated with numbness of the lip)	
  Referral is due to clinical concerns that do not meet above criteria - please provide full description in Section 1

Please note: unilateral sensorineural hearing loss is not a symptom of head and neck cancer. Please refer patients with this symptom via the normal channels. 

Please note: Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either a lump on the lip or in the oral cavity or a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.

If no specific criteria are met, consider seeking Advice and Guidance from a specialist before referring urgently	
Clinical risk factors
 Alcohol history,   HPV,   HIV,   Previous irradiation to head and neck,  
 Family history of thyroid cancer,
 Ex-smoker,   Oral tobacco use,    Current smoker If yes:       packs per day        years smoked 	

5.	INFORMATION FOR HOSPITAL ASSESSMENT – ESSENTIAL	
WHO Performance status	
   0   Fully active
   1   Restricted physically but ambulatory and able to carry out light work
   2   Ambulatory more than 50% of waking hours; able to carry out self-care
   3   Limited self-care; confined to bed or chair more than 50% of waking hours
   4   Completely disabled; cannot carry out any self-care. The patient is totally confined to bed or chair	
Other access needs - Please detail per the selected options in the field below	
  Interpreter required   If Yes, Language:      
  Transport required.
  Mobility needs 
  Wheelchair access required	   Cognitive impairment including dementia
   Learning disability 
   Autism
   Mental health issues that may impact on engagement
   Severe mental illness	
Details of access needs:      	

6.	ADDITIONAL IMPORTANT CLINICAL INFORMATION 	
Past history of cancer:      	
Relevant family history of cancer:      	
Safeguarding concerns:      	
Other relevant information about patient’s circumstances:      	
Patient referred/previously investigated for similar symptoms at other hospital/service?     
 No      Yes, please give details:     	

   I have discussed the possible diagnosis of cancer with the patient	
   I have provided the patient the urgent fast track referral leaflet (Patient Information & Safety Netting)	
   I have advised the patient to prioritise this appointment & confirmed they’ll be available within the next 14 days.	
   The patient has been advised that the hospital care may contact them by telephone	
   Patient added to the practice safety-netting system      	
If any of the 5 boxes above are not ticked, please provide an explanation: 
     	

7.	CONSULTATIONS, PAST MEDICAL HISTORY, MEDICATIONS AND INVESTIGATIONS	
Please note: You will need to add pending test results, requests and relevant excluded medical history (e.g. trans history, sexual health, private patients) manually in the text boxes below.	
Consultations: Consultations 	
Medical history: Problems	
Medication: Medication  	
Allergies: Allergies 	
Imaging studies (in the past 12 months):  Date:        Location:      	
     	
Thyroid  function (in the past 6 months):      	
Full blood count (in the past 6 months):      		
Test results pending (type of investigation) :       Trust / Organisation:       Date:       
     	
All Values and Investigations (in the past 3 months): 
Investigations	
BMI (latest): BMI 	
Weight (latest): Weight 	
Blood Pressure (latest): Blood Pressure 	
Alcohol consumption (units per week) Alcohol Consumption 	
Smoking status: Smoking 	
Safeguarding history:      	

Trust Specific Details

Please note:
-	North Bristol Trust does not have a Head and Neck cancer service

For hospital to complete	UBRN:
				Received date:

Refer to:
UHB