Cancer Referral form - Upper GI

UPPER GI
Suspected Cancer Referral
(2 Week Wait Referral)
To support NICE guidance 2005
Please FAX within 24 hours to the Cancer Referrals Office on:
01708 435074 or 01708 435367
Section 1 PATIENT INFORMATION (Please complete in BLOCK CAPITALS)
SURNAME
Date of Referral / /
Date of Birth / /
FIRST NAME
NHS number
UBRN - -
Miss Mrs Ms Mr Other: _________ M [ ] F [ ] Home Tel.
Address
Post Code
Mobile/Daytime Tel.
Transport Y N Interpreter Y N
Language
Section 2 PRACTICE INFORMATION (Please use practice stamp if available)
Referring GP Locum Y N
Practice Address
Telephone
Fax
Post Code
Section 3 CLINICAL INFORMATION (please TICK all applicable entries)
Symptoms that may require gastroscopy as 1 st appointment
With or without dyspepsia and:
Dyspepsia and:
[ ] Dysphagia [ ] Chronic gastrointestinal bleeding
[ ] Epigastric mass [ ] Iron deficiency anaemia
[ ] Persistent vomiting and weight loss [ ] Suspicious barium meal result/CT/USS
[ ] Progressive unintentional weight loss [ ] Aged > 55 yrs with unexplained persistent, recent onset*
Consider in worsening dyspepsia and: * Recent onset means NEW and not a recurrence of previous dyspepsia
[ ] Barrett’s oesophagus Persistent defined as longer than expected (usually > 6 weeks)
[ ] Peptic ulcer surgery > 20 years Unexplained after history/GP investigations
[ ] Known dysplasia, atrophic gastritis,
intestinal metaplasia
In case of uncertainty, please contact your local specialist (see local contacts on guideline)
Symptoms that may require an outpatient visit as 1 st appointment
[ ] Jaundice (urgent USS if possible) [ ] Upper abdominal mass
PLEASE ENCLOSE PRINTOUTS OF CURRENT MEDICATIONS and PAST MEDICAL HISTORY
All Medication
Significant Medical History, Known Allergies
DIABETIC: YES / NO
WARFARIN: YES / NO
ACID SUPPRESSION MEDS
STOPPED: YES / NO
Investigations
FBC: YES / NO Date: ___/___
Hb :
• Discussed urgent suspected cancer referral with patient Y N
• Have you told the patient that they may have a gastroscopy Y N
Comments /other reasons for urgent referral
Hospital use only: (Tick where appropriate)
Date Appointment Booked: / / Date of Referral receipt: / /
Target Dates 2ww / / Database: Patient confirmed:
62/7 / /
A separate letter need accompany only if you consider it necessary.
Approved by the North East London Cancer Network April 2006_REVISED April 2009_AM

LOCAL CONTACT DETAILS
Cancer Waiting Times Co-ordinator Tel. 01708 435169 Queen’s Hospital
CRITERIA 1 FOR URGENT SUSPECTED CANCER REFERRAL
Please FAX the referral form within 24 hours
Refer a patient who presents with symptoms suggestive of upper GI cancer to a team
specialising in the management of upper GI cancer, depending on local arrangements.
Helicobacter pylori status should not affect the decision to refer for suspected cancer.
Note that for patients