<p>Gloucestershire PCT Three Counties Cancer Network Gloucestershire Hospitals</p><p>2 Week Wait Urgent Referral to a Breast Clinic: GP Proforma V2 Blank </p><p>Patient’s details Patient’s background and culture Surname: Ethnicity: Forename: First language DOB: Interpreter required? Y N Sex GP details Title Referring GP: Patient Practice Address address: Postcode: GP Tel no: NHS No GP Fax no: Hospital No Date of referral Home tel Date Referral Work tel Received Mobile tel If cancer is suspected, is the patient aware? Y N Cancer not suspected Is the patient available for an appointment within the next 14 Y N (Needs to be available) days? Please indicate patient’s preferred contact number: Home Work Mobile </p><p>Breast Symptoms  Examination Breast Cancer suspected Any age with a discrete, hard lump with fixation, with our without skin tethering, or which enlarges Female aged 30+ with a discrete lump that persists after their next period, or presents after menopause Any age with previous breast cancer, who present Right Left Bilateral with a further lump or suspicious symptoms Unilateral eczematous skin or nipple change that does not respond to treatment Duration: weeks Months Nipple distortion of recent onset Spontaneous unilateral bloody nipple discharge Male aged 50+ with a unilateral firm mass under or near nipple with or without nipple distortion or associated skin changes Non cancer symptoms</p><p>Where Relevant Imaging When</p><p>Please indicate if you are attaching a letter Y N </p><p>Performance 0 - Able to carry out all normal activity without restriction Status 1 - Restricted in physically strenuous activity, but able to walk and do light work Please 2 - Able to walk and capable of all self-care, but unable to carry out any work. Up and about more than 50% of waking hours indicate 3 - Capable of only limited self-care, confined to bed or chair more than 50% of waking hours 4 - Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair Current Medication </p><p>Relevant PMH</p><p>13/12/2013 Gloucestershire PCT Three Counties Cancer Network Gloucestershire Hospitals Allergies </p><p>Additional Information For submission via NHS E-Referrals Appointments Office : 03004 223785 / Fax: 01242 697702</p><p>Nov 2015</p><p>13/12/2013</p>