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HEAD & NECK CANCER SELF REFERRAL FORM

Head & Neck Cancer Self Referral Questionnaire

By completing this form, you are accepting that we access your medical records. The head and neck team will triage this form accordingly and we shall contact you in due course if you fulfil the criteria. If you are concerned about your symptoms or have not been contacted after 4 weeks, please contact your GP or health care provider to make an appointment.
This form will be available until the 6th January 2023.
1.Are you 45 years or older?
2.Are you a Smoker
3.Do you drink more than 30 units of alcohol a week?
Reference: 1 beer (330ml) = 1.5 / 125 mls wine = 1.5 unit / 1 spirit unit = 1.5
4.Do you have any of the following symptoms for more than 3 weeks? (Can choose more than 1)
5.Please enter your GHA number(Required.)
6.Please confirm your GHA number
7.Please confirm your preferred contact number(Required.)
8.Any other relevant information you feel we should know