URGENT SUSPECTED CANCER (2WW) REFERRAL FORM FOR ADULTS
SUSPECTED GYNAECOLOGICAL CANCERS 
(Including Ovarian, Endometrial, Cervical, Vulval and Vaginal)	
Advice and Guidance should be considered if there is uncertainty about the interpretation of symptoms and signs, and whether a referral is needed. This may also enable the primary healthcare professional to communicate their concerns and a sense of urgency to secondary healthcare professionals when symptoms are not classical
PATIENT ENGAGEMENT – THIS IS A MANDATORY FIELD	
Has the patient been counselled they are being referred to a suspected cancer service and the reason for referral? 
NICE ng12  guidance/ patient support
	Yes    No     	
Has the patient been given relevant written information about this referral?
 	Yes     No     	
Is the patient available within the next 14 days? 
If selected no, please explain why? 	Yes     No     	
Have you checked all contact details are correct and informed the patient that the initial appointment may be by telephone?	Yes     No     	
REFERRER DETAILS	
Referring GP		GP Code		
Usual GP		
GP Address 		
GP Tel. No. 			
GP secure email		
Date seen by GP		Decision to refer date		
PATIENT DETAILS	
Title & Surname		Forename(s)		
Date of Birth		Age		Gender		
Address		
Home Tel No.		Work Tel No.		
Mobile Tel No.		Patient email	 	
Next of Kin/Chosen representative   	Permission Given:
Yes    No   
  	Name and contact details if patient gives permission to speak to them.	

REFERRAL INFORMATION	
Main Reason for Referral  NICE NG12 suspected cancer referral guidance/gynae 

Family History

No events found.  	
Menopausal status       
Pre-menopausal                 
Post-menopausal    
Menstrual data if relevant:   	
Hysterectomy   Yes          No      
No events found.  	HRT                  Yes    No   
  
If using HRT please specify 

Please select type of cancer suspected 
Ovarian            Endometrial              Cervical           Vulval              Vaginal     	
Ovarian Cancer 	
Please refer to the NICE ovarian cancer pathway to ensure that all the necessary examinations and investigations have been performed prior to this referral.	
•	Ascites +/- pelvic or abdominal mass (which is not obviously uterine fibroids)	   	
•	Patient has Ultrasound suggestive of ovarian cancer and results are attached	  	
Ca 125 taken: 
Result:
 
Date of last Measurement: 
	If not done recently (within 6 weeks) have you arranged urgently?   Yes    No  
If result not pulled through enter manually here:  
	
Endometrial Cancer	
•	Any age with post-menopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause)
Starting or changing HRT can result in unscheduled vaginal bleeding in the first few months. If uncertain use advice and guidance 	   
  	
•	USS indicates possible endometrial cancer (any age) – with report attached
Refer to NICE NG 12 Guidance Endometrial  for indications for direct access USS investigation (PV discharge, visible haematuria etc.)	   
No events found.  	
•	CT indicates possible endometrial cancer (any age) – with report attached	  
  	
Cervical Cancer 	
•	Appearance of cervix consistent with cervical cancer (Please describe Cervix)
Cervix Chart	  
	
Most recent Smears date: 
Cervical Screening Result	
Cervical smear: 
    	
Vulval Cancer	
•	Unexplained vulval lump 
     (please describe) 	  
	
•	Unexplained vulval ulceration 
(please describe) 	  	
•	Unexplained vulval bleeding
 (please describe) 	  
	
Vaginal Cancer	
Unexplained palpable mass in or at the entrance to the vagina

SERVICE SPECIFIED INVESTIGATIONS /OTHER EXAMINATIONS
INCLUDING THIS INFORMATION MAY PREVENT DELAYS IN ASSESSMENT OR TREATMENT 	
Height 		
Weight 		
BMI		
BP		
Is patient taking anticoagulants?		
Is Patient taking antiplatelets?		
 Blood Tests: please ensure results pull through ‘investigations’ below, or are attached  	
 Full Blood Count  	Ferritin 	Renal Function	
 Liver function	Thyroid function	Ca125 	
CLINICAL PERFORMANCE WHO	
WHO performance status and if patient is 65 years or over a Clinical Frailty (Rockwood) scale is requested. Please involve your patient in this assessment.	
0. Able to carry out normal activity without restriction
1. Restricted in strenuous activity but ambulatory and able to carry out light work 
2. Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than     50% of waking hours
3. Symptomatic and in a chair or in bed for greater that 50% of the day but not bedridden
4. Completely disabled; cannot carry out any self-care; totally confined to bed or chair
WHO performance Score     No events found.	
ROCKWOOD FRAILTY SCORE
1.Very fit; 2. Fit; 3. Managing Well; 4.Vulnerable; 5.Mildly Frail; 6.Moderately frail; 7.Severely frail; 8.Very severely frail
Rockwood CFS Descriptors    Rockwood Top Tips       
         No Frailty score recorded. Enter manually if any.	
CULTURAL, MOBILITY STATUS AND ASSISTANCE REQUIREMENTS	
Does the patient have any Communication, Mobility or Safeguarding needs (Including reduced capacity)?
If patient has reduced capacity, please ask permission to speak to next of kin/chosen representative and enter those contact details in “patient details” section on page 1.
	Yes       No   

   
  	
Please detail if there are any reasonable adjustments needed or additional requirements	 	
If the patient requires Translation or Interpretation Services 
Please give details:	Yes          No     
      	
What is the patient’s preferred first language?	unknown 	
LGBQT+ Status if patient wishes it to be added 		
Ethnicity		
Religion (if recorded)	 	
Temporary resident	Yes          No	
Overseas visitor  	Yes          No	
Military Veteran Status
	 Yes          No 	
In your clinical opinion, does the current condition relate to their military service and require priority treatment. Please give details:

	Yes          No 

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