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E-Mail Address: Fax Number: Bleep:: Bloods, Chest X-Ray Etc)

This document is a proforma for a neuro-oncology multidisciplinary team meeting. It requests patient information such as their name, date of birth, NHS number, address, next of kin, referring doctor details, history of presenting complaint, clinical findings from scans and tests, weight, past medical history, current medications, performance status, fitness for anaesthetic, and neurological status. Additional sections are available to provide specific questions for the multidisciplinary team and any other relevant information.

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Mukundan Subramanian
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103 views2 pages

E-Mail Address: Fax Number: Bleep:: Bloods, Chest X-Ray Etc)

This document is a proforma for a neuro-oncology multidisciplinary team meeting. It requests patient information such as their name, date of birth, NHS number, address, next of kin, referring doctor details, history of presenting complaint, clinical findings from scans and tests, weight, past medical history, current medications, performance status, fitness for anaesthetic, and neurological status. Additional sections are available to provide specific questions for the multidisciplinary team and any other relevant information.

Uploaded by

Mukundan Subramanian
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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Office use only

KCH Patient Number

Kings College Hospital Neuro-oncology MDT Proforma PLEASE ANSWER ALL QUESTIONS ON BOTH PAGES. Please complete electronically and email to [email protected] For further Information please call Donna Neuro-oncology Coordinator on 020 3299 4151 Date of Referral: Hospital and Ward: Patients Name Consultant: Date of Birth NHS Number Patients telephone no. Referring Doctor Referrer Contacts E-mail Address: Fax Number: Bleep:

Patients Address Next of Kin Name and Tel. Number GP name and address + Tel Number HISTORY OF PRESENTING COMPLAINT(Date of admission / clinic etc):

SPECIFIC QUESTION FOR MDT: CLINICAL FINDINGS: (Please include a brief report below or email reports with proforma) Yes No Date: Report:

MRI Head/ Spine

CT Head/Spine

Yes No

Date: Report:

CT CAP

Yes No

Date: Report:

Other: (Lumbar Puncture, Bloods, Chest x-ray etc)


Kings Neuro-oncology MDT proforma

PATIENT WEIGHT: SURGICAL PROCEDURE (if any): PAST MEDICAL HISTORY:

PREVIOUS DAIGNOSIS OF CANCER: TREATMENT GIVEN: CURRENT MEDICATIONS: (Including information on anti-coagulant medication, if stopped when?)

CURRENT PERFORMANCE STATUS: Use table below for descriptions: 0 1 2 3 4 5 Asymptomatic (Fully active, able to carry on all pre-disease activities without restriction) Symptomatic but completely ambulatory (Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature. For example, light housework, office work) Symptomatic, <50% in bed during the day (Ambulatory and capable of all self care but unable to carry out any work activities. Up and about more than 50% of waking hours) Symptomatic, >50% in bed, but not bedbound (Capable of only limited self-care, confined to bed or chair 50% or more of waking hours) Bedbound (Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair) Death

PATIENT FIT FOR GENERAL ANAESTHETIC? CURRENT NEUROLOGICAL STATUS (GCS/Pupils/Focal Neurology): Confirm patient has had MRSA swabbing If available Result: Date:

ANY ADDITIONAL INFORMATION:

Print Name:

Date:

Kings Neuro-oncology MDT proforma

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