Neck Lump - The Royal Wolverhampton Hospitals NHS Trust

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Neck Lump - The Royal Wolverhampton Hospitals NHS Trust

Cancer Suspicious Neck Lumps

Patient Details

Surname:

Address:

First Name:

Phone No:

Date of Birth:

G.P. Details:

Name:

Sex:

Phone No:

Hospital No:

Fax No:

Date of decision to refer:

Address:

Special Needs Yes

No

Details:

Discussed urgent suspected Cancer referral with patient Yes No

Referral Criteria

Applies

Any Neck Lump recently noticed or changed over 3-6 weeks

Thyroid enlargement previously undiagnosed

Solitary or dominant node increasing in size

History of neck irradiation

Family history of endocrine cancer

Salivary Glands

Parotid Mass +/- Facial Palsy

Submandibular mass

Enlarged Lymph nodes in the neck

Any other neck lump / Mass of concern


Other Information

Smoker ? Yes No Ex Smoker

Ceased smoking

Date patient first presented to you with any of the above symptoms

Background / Past History to include details of any previous cancer:

Allergies:

Current Medication:

Fast Track Appointment: Referral accepted: Yes No

Date of appointment:

Clinic code:

If No – GP advised referral has

been forwarded for consultant

consideration and an appointment

will be arranged in due course

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