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Lung Form

In: Social Issues

Submitted By aishammd0112
Words 742
Pages 3
If you wish to include an accompanying letter, please do so. On

(Version 2.0)

completion please FAX to the number below.

These forms should only be used for suspected cancer and in conjunction with the NICE Referral Guidelines for Suspected Cancer, June 2005

Patient Details

Hospital No


GP Details (inc Fax Number)


Date of Decision to Refer
Date of Referral
GP Signature

First Language:

Symptoms for immediate referral: Note:Do not use this form for immediate referral, make a telephone referral
♦ Signs of superior vena caval obstruction (swelling of face/neck with fixed elevation of JVP)
♦ Stridor
Symptoms for urgent referral: (Check as appropriate)
Persistent haemoptysis (smokers/ex-smokers > 40 yrs)
Chest x-ray suggestive of lung cancer (inc pleural effusion and slowly resolving consolidation)
Normal chest x-ray with high suspicion of lung cancer
Symptoms for urgent referral for a chest x-ray: Note: Do not use this form for routine referral for a chest x-ray

Changes in symptoms in patients with underlying chronic respiratory problems
Unexplained or persistent (longer than three weeks): (See below)
♦ Weight loss
♦ Chest/shoulder pain
♦ Chest signs
♦ Finger clubbing
♦ Dyspnoea
♦ Cervical/supraclavicular lymphadenopathy
♦ Hoarseness
♦ Cough
♦ Features suggestive of metastasis from a lung cancer (e.g. secondaries in the brain, bone, liver, skin)
Current or ex-smoker
History of exposure to asbestos and recent onset of chest pain
History of COPD
Previous cancer (especially head & neck)
Shortness of breath or unexplained systemic symptoms (where chest x-ray indicates pleural effusion, mass or suspicious lung pathology)
Clinical Details:…...

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