Suspected brain cancer 2 week wait referral	

Date of decision to refer:	Short date letter merged  	Date referral received at Trust:  	     	

Patient Details	Surname: Surname  	First Name: Given Name  	Title: Title  	
	Gender: Gender(full)  	DOB: Date of Birth  	NHS Number: NHS Number  	
	Ethnicity: Ethnic Origin  	Language: Main Language       	
	Interpreter required: Interpreter required   	Transport required:      	
	Patient Address: 
Home Full Address (stacked)  	
	Contact numbers:	
	Home: Patient Home Telephone  	Mobile: Patient Mobile Telephone  	Email: Patient E-mail Address       	
Practice Details	Registered GP Name: Registered GP Full Name  	
	Practice Name: Registered GP Organisation Name 
Registered GP Full Address (stacked)  	
	Direct line to the practice (Bypass):      	
	Main: Registered GP Phone Number 	Fax:      	Email: Organisation E-mail Address       	
	Referring Clinician:      	

SPECIFIC 2 WEEK WAIT REFERRAL INFORMATION:
 Progressive, sub-acute loss of CNS function - Urgent referral for imaging, ideally MRI, or CT scan if MRI is contraindicated (if available locally) otherwise refer directly to neurology.
 <25y with new abnormal CNS or cerebellar function; Arrange review within 48h	

Please describe reasons for suspected brain tumour:
     	

Blood results (ESSENTIAL)
Please ensure the following recent blood results are available (U&Es must be within 4 weeks): See also “values and investigations” below      
Na Single Code Entry: Serum sodium level... K Single Code Entry: Serum potassium level... eGFR Single Code Entry: GFR (glomerular filtration rate) calculated by abbreviated Modification of Diet in Renal Disease Study Group calculation... (tumour markers are only indicated for disease monitoring)	

	The patient is aware that this is a fast track referral to exclude brain cancer	
	The patient has been provided with a cancer pathway leaflet	
	The patient is aware and able to attend an outpatient appointment within the next two weeks	

Please tick YES if any of the following apply to your patient: 
	Patient not suitable for MRI imaging (patient choice or contraindication)	
	Patient has cognitive impairment that may affect their mental capacity for consent. 
If yes, please confirm date best interests meeting completed:      	
	Patient has significant mobility impairment	
	Patient has significant sensory impairment (specify):      	
	Patient will require an interpreter (specify):      	

Single Code Entry: WHO performance status grade 0...    
Clinical Information	
WHO Performance Status (please tick)	
	 0
 1
 2
 3
 4	Fully active
Restricted in physically strenuous activity but ambulatory and able to carry out light work
Ambulatory and capable of self-care, unable to carry out work activities, up & about 50% of waking hours
Capable of only limited self-care, confined to bed/chair 50% of waking hours
No self-care, confined to bed/chair 100%	
	Details of other significant medical history: See below      
	
	Anticoagulation and / or antiplatelet medication – please state indication, medication taken and latest INR if applicable:
See below      
List or attach regular medication: See below      	
Problems 

Medication 

Allergies 

Values and Investigations 

Full Name 	Date of Birth 	NHS Number