FAX THIS FORM TO ANY ONE OF THE FOLLOWING LUNG CANCER FAST TRACK CLINICS	
DUBBO HEALTH SERVICES	Dr S. MALLAWATHANTRI	

DR C. PRABHAKAR	

	Ph: 02 6841 2416 Fax 02 6881 6569 
Email: wnswlhd-ccdubsmc@health.nsw.gov.au	
ORANGE HEALTH SERVICES	DR K. SINGH	Ph: 02 6369 7352 Fax: 02 6360 2005	

Patients Details		General Practitioner Details	
Surname: <<Patient Demographics:Surname>>
First Name: <<Patient Demographics:First Name>>
DOB: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Full Address>>

Mobile No: <<Patient Demographics:Phone (Mobile)>>          Phone no: <<Patient Demographics:Phone (Home)>>
Medicare No: <<Patient Demographics:Medicare Number>>
DVA: <<Patient Demographics:DVA Number>>
Private Health Insurance:<<Patient Demographics:Health Insurance>>
Gender: <<Patient Demographics:Gender>>		Name: <<Doctor:Name>>
Address: <<Doctor:Full Address>>

Phone: <<Doctor:Phone>>                  
Fax: <<Doctor:Fax>>

GP Signature: _____________________________
Date of Referral:<<Miscellaneous:Date>>
Provider Number: <<Doctor:Provider Number>>	

Referral Information 	
Any of the Following unexplained persistent symptoms and signs lasting 3 weeks (or less than 3 weeks in people with known risk factors:	
<<Does Patient have new or changed cough?>>  New or Changed Cough
 <<Does pt chest or should pain dyspnoea?>>  Chest and or Shoulder pain dyspnoea
<<Does pt have weight loss / Loss of appetite?>>   Weight loss / Loss of appetite
<<Cervical and/or supraclavicular lymphadenopathy?>>         Cervical and/or supraclavicular lymphadenopathy
 <<Features suggestive of metastasis from a lung canc>>        Features suggestive of metastasis from a lung cancer (For example in brain, bone, liver or skin)
	<<Does patient have signs of pleural effusion?>>         Signs of pleural effusion
<<Does patient have Unresolved chest infection?>>         Unresolved chest infection
<<Does patient have Hoarseness?>>          Hoarseness
<<Does Patient have Finger Clubbing?>>          Finger Clubbing
<<Does patient have Abnormal chest sounds?>>          Abnormal chest sounds
<<Does patient have Haemoptysis?>>          Haemoptysis
Smoking Status: <<Clinical Details:Smoking>>  	

Chest x-ray - Please enter details below
Date of Chest x-ray: 
Radiology Facility:
Normal:
Abnormal:	CT Scan (if done)  - Please enter details below
Date of CT scan:
Radiology Facility:
Normal: 
Abnormal:	

WHO Performance Status
1	Fully active, no restriction on activities
2	Unable to do strenuous activities but can carry out light housework and sedentary activities
3	Able to walk and manage self-care, but unable to work. Out of bed more than 50% of waking hours
4	Confined to bed or a chair more than 50% of waking hours. Capable of limited self-care
5	Completely disabled. Totally confined to a bed or chair. Unable to do any self-care	Co-morbidities present: <<Co-morbidities present?>>       

Explain: <<Explain Co-morbidities present:>>

On Antiplatelet Therapy:  <<Is patient on any Antiplatelet Therapy?        >>  
On Anticoagulant Therapy:  <<Is patient on Anticoagulant Therapy?      >>     
	
FOR HOSPITAL USE ONLY:	
Date referral received  ________________                                                             Respiratory Clinic Triage
Date of appointment _________________                                                         c   Urgent Referral (To be seen within 2 weeks)
                                                                                                                             c   Routine Referral