This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.
Presenting Complaint
Main Presenting Complaint: [Text – 98 character maximum]
Reason for Referral: [Text]
World Health Organisation Performance Scale
Using the following as a guide, please select the most appropriate answer to describe the patients general health:
Options:
- Asymptomatic
- Symptomatic but completely ambulatory
- Symptomatic, <50% in bed during the day
- Symptomatic, >50% in bed, but not bedbound
- Bedbound
Priority: Urgent Suspicion of Cancer
Date of Onset: [Date]
Will the patient accept any site for treatment:
- Yes
- No
Symptoms and Investigations
Symptoms
History – Please add more details where required.
Fatigue:
- Yes (If Yes, please provide brief details)
- No
Night Sweats:
- Yes (If Yes, please provide brief details)
- No
Weight Loss:
- Yes (If Yes, please provide brief details)
- No
Itching:
- Yes (If Yes, please provide brief details)
- No
Breathlessness:
- Yes (If Yes, please provide brief details)
- No
Bruising:
- Yes (If Yes, please provide brief details)
- No
Recurrent Infections:
- Yes (If Yes, please provide brief details)
- No
Bone Pain:
- Yes (If Yes, please provide brief details)
- No
Polyuria and polydipsia (with normal glucose)
- Yes (If Yes, please provide brief details)
- No
Clinical Examinations
Hepatomegaly:
- Yes (If Yes, please provide brief details)
- No
Splenomegaly:
- Yes (If Yes, please provide brief details)
- No
Lymphadenopathy greater than 2cm over 6 weeks:
- Yes (If Yes, please provide brief details)
- No