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
Date of Onset: Date
Priority: Urgent Suspicion of Cancer
Is this a fast track referral of a previous breast cancer:
- Yes
- No
Is there a suspicion of bilateral disease:
- Yes
- No
Will the patient accept any site for treatment:
- Yes
- No
Protocol Specific Questions
HRT History:
- Never
- Previously
- Current
Number of years on HRT: [Text]
Menopause Status:
- Pre-Menopausal
- Menopausal
- Post-Menopausal
- Male patient or not applicable
Last Menstrual Period: [Date]
Is there a family history of breast cancer:
- Yes
- No
If yes to previous question, please give relationship and age at diagnosis: [Text]
Previous Mammograms: [Text (please provide date and location or N/A)]
Previous Ultrasounds: [Text (please provide date and location or N/A)]
Previous Breast Clinic appointments: [Text (please provide date and location)]
Breast Examination
Left Breast
Is there any left breast abnormality present:
- Yes
- No
Left breast abnormality: [Text (Please accurately describe the location and type of abnormality)]
Left breast degree of suspicion:
- Uncertain
- Probably Benign
- Probably Malignant
Right Breast
Is there any right breast abnormality present:
- Yes
- No
Right breast abnormality: [Text (Please accurately describe the location and type of abnormality)]
Right breast degree of suspicion:
- Uncertain
- Probably Benign
- Probably Malignant