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["\n\nSOUTH WALES  \nGYNAECOLOGICAL ONCOLOGY MDT REFERRAL FORM\n"]
["Date of Referral","     ","Has this patient been discussed previously?"]
[]
["PATIENT DEMOGRAPHICS:"]
["Forename",null,"     ",null,null,"Address & Postcode"]
["Surname",null,null,null,null,null,null,null,null,null,null,"Pick option below"]
["DOB",null,"     ",null,null,null,null,null,null,null,null,"Bronglais"]
["Hospital Number",null,"     ",null,null,null,"Tel no: ","     ",null,null,null,"Prince Philip"]
["GP Name:","     ",null,"Surgery details:",null,null,null,null,null,null,null,"Glangwili"]
[null,null,null,null,null,null,null,null,null,null,null,"Withybush"]
["REFERRAL DETAILS:",null,null,null,null,null,null,null,null,null,null,"Singleton"]
["Referring Consultant:","     ",null,null,"Referring Hospital:",null,null,null,null,null,null,"Morriston"]
["Referral type:",null,null,null,null,null,null,null,null,null,null,"Neath Port Talbot"]
["Reason for MDT Review:",null,null,null,null,null,null,null,null,null,null,"Princess of Wales"]
["Diagnosis / Provisional Diagnosis:",null,null,null,null,null,"Is patient aware of diagnosis:   ",null,null,null,null,"Royal Glamorgan"]
[null,null,null,null,null,null,null,null,null,null,null,"Prince Charles"]
["CLINICAL INFORMATION:",null,null,null,null,null,null,null,null,null,null,"UHW"]
["Date seen by clinician:",null,null,"Menopausal status:",null,null,null,null,null,null,null,"Llandough"]
["Presenting symptoms:",null,null,null,null,null,null,null,null,null,null,"Royal Gwent"]
["Past medical history:",null,null,null,null,null,null,null,null,null,null,"Nevill Hall"]
["Examination findings: ",null,null,null,null,null,null,null,null,null,null,"Velindre"]
["Risk of Malignancy Index (Mandatory if pelvic mass):",null,null,null,"To calculate RMI use:  USS Score (1 or 3) x Menopausal status (1 or 3) x CA 125 level"]
["Performance Status:",null,null,null,"Height (cm):",null,"Weight (Kgs)",null,"BMI:",{"$f":"Weight/((Height*Height)/10000)","v":{"$error":"#DIV/0!"}},null,"Pick option below"]
[null,null,null,null,null,null,null,null,null,null,null,"0 - Asymptomatic"]
["INVESTIGATIONS PERFORMED:",null,null,null,null,null,null,null,null,null,null,"1 - Symptomatic but completely ambulatory"]
["Radiological",null,null,null,null,null,null,null,null,null,null,"2 - Symptomatic, <50% in bed during the day"]
["Investigation",null,"Date",null,"Local Case Record Number",null,"Hospital where performed",null,null,null,null,"3 - Symptomatic, >50% in bed but not bedbound"]
["     ",null,"     ",null,null,null,null,null,null,null,null,"4 - Bedbound"]
["     ",null,"     "]
["     ",null,"     "]
[]
["Histology"]
["Investigation",null,"Date",null,"Local Case Record Number",null,"Hospital where performed"]
["     ",null,"     ","     "]
["     ","     ","     ","     "]
[]
["Other relevant investigations (eg Tumour Markers)"]
["Investigation",null,null,"Date",null,"Result"]
["     "]
["     ","     "]
[]
["Treatment to Date:"]
["Date:","     ","Details:","     "]
["Date:","     ","Details:"]
[]
["SUMMARY AND CLINICAL QUESTION TO BE ADDRESSED: (Mandatory field, your form may be returned without this)\nUpdate in box below.  To start a new line, use Alt+Return."]
[]
[]
["Only refer to one team",null,null,null,"PLEASE NOTE:  All referrals must be completed electronically and sent using the buttons to the left by Friday 12:30pm for discussion at the next MDT.  For Pathology review, slides should be submitted a week before MDT discussion.  All radiological investigations should be sent to the relevant PACS for review by the Friday before MDT discussion.\nPlease be aware that patients may be reviewed in clinic either before or after the initial MDT discussion"]
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["Version 1.5 July 2018"]