Breast Referral - The Royal Wolverhampton Hospitals NHS Trust

royalwolverhamptonhospitals.nhs.uk

Breast Referral - The Royal Wolverhampton Hospitals NHS Trust

Breast Referral

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:

Cancer Suspicious Symptoms-

Discussed urgent suspected Cancer referral with patient Yes No

Women Any age -

Discreet hard lump or lump with fixation (with or without skin

tethering)

Location- Left Breast Right Breast Bilateral

RUQ

LUQ

RUQ

LUQ

Position & size

RLQ LLQ of Lump

RLQ LLQ

How long has Patient been aware of lump:

Unilateral

Spontaneous bloody nipple

Eczematous skin or nipple change (not responding to treatment

nipple distortion (recent onset)

Previous histological confirmed breast cancer, Lump or suspicious symptoms

Men Aged 50+

Unilateral, firm subareaolar mass


Symptomatic Breast Symptoms

34 Years and under Over 35 Years

Location- Left Breast Right Breast Bilateral

RUQ

LUQ

RUQ

LUQ

Position & size

RLQ LLQ of Lump

RLQ LLQ

How long has Patient been aware of lump:

Persistent / Recurrent cyst Nipple Discharge Abscess

Nodularity

Pain-

Low long has the pain existed

Nipple Eczema

family history:

Details

reconstruction for breast ca

Previous

mammogram

Date of last

mammogram

Yes

No

Previous problems

with their breast

Yes

No

Current / previous use

of HRT

Yes

No

Family history of

breast cancer

Yes

No

Fast Track Appointment:

Date form received:

Date of appointment:

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