[% content_only = 1 # no html wrappers %]
<!-- BEGIN [% template.name %] -->
<!doctype html>
<html lang='en'>
<head>
<link type="text/css" rel="stylesheet" href="/css/wgs-referral-form.css" />
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
</head>
<body>
[% IF requests.size AND NOT c.stash.render_pdf %]
<p class="printInfo printHide">ENSURE PRINT BACKGROUND COLOURS SETTING IS
ON AND PAGE MARGINS ARE SET TO ZERO IN PRINTER SETUP</p>
<p class="indent printHide">[% site.html.back_button %]</p>
[% END %]
[% # INCLUDE dumper.tt dump = t.as_tree FOREACH t IN ngis_tests %]
[% IF requests.size;
FOREACH r IN requests; # INCLUDE dumper.tt dump = r.as_tree;
result_summary = r.results_summary.results_summary;
patient = r.patient_case.patient;
# sample_dispatched & germline requests:
FOREACH t IN r.lab_test_results; # INCLUDE dumper.tt dump = t;
NEXT UNLESS t.lab_test.test_name.match('sample_type');
sample_dispatched = t.result;
LAST;
END; # INCLUDE dumper.tt dump = sample_dispatched;
germline = 1 IF NOT sample_dispatched.match('blood|marrow');
# ngis test codes:
FOREACH t IN ngis_tests; # INCLUDE dumper.tt dump = t.as_tree;
# TODO: how to link ngis_test_code to results_summary ?
END;
%]
<p class="rightAlign">Version 1.7</p>
<div class="wgs">
<table border=0>
<tr class="borderless">
[% img_src = c.stash.render_pdf ? 'http://localhost/images' : '/images' %]
<td class="bold" style="width:60%">
<div>Genomic Medicine Service</div>
<div>Whole Genome Sequencing (WGS) Test Request</div>
<div>PLEASE DO NOT USE FOR NON-WGS TESTS</div>
</td>
<td style="width:110px">
<img src="[% img_src %]/wgs_cancer.png" />
</td>
<td style="width:140px">
<img src="[% img_src %]/nhs.png" />
</td>
</tr>
</table>
<div class="spacer-5"></div>
<table border=0>
<tr>
<td colspan="2">Requesting organisation:
[% r.patient_case.referral_source.display_name %]
</td>
</tr>
<tr>
<td style="width:70%">GLH laboratory to receive sample:
YNEGLH Leeds Central Lab
</td>
<td>Test Required<br />Whole Genome Sequencing</td>
</tr>
</table>
<div class="spacer-5"></div>
<table border=0>
<tr>
<td colspan="2" style="width:50%">Patient first name:
[% patient.first_name.ucfirst %]
</td>
<td>
<div>Ethnicity</div><div>(Please tick on page 2)</div>
</td>
</tr>
<tr>
<td colspan="2">Patient last name:
[% patient.last_name.upper %]
</td>
<td class="topAlign" rowspan="3">
<div>Test Directory Clinical Indication & code</div>
<!-- <div>(cancer type and reason for testing)</div> -->
[% # TODO: this should be derived from ngis_lab_test data
IF result_summary.match('AML|myeloid'); 'M80.1';
ELSIF result_summary.match('ALL|lymphoblastic'); 'M91.1';
END;
%]
</td>
</tr>
<tr>
<td><div>Date of birth</div><div>[% patient.dob.dmy('/') %]</div></td>
<td class="topAlign">
<div>Hospital number</div>
<div>[% r.patient_case.unit_number %]</div>
</td>
</tr>
<tr>
<td colspan="2">
<div>Gender</div>
<div>
<input type="checkbox"
[% 'checked' IF patient.gender.match('M') %] />
Male
<input type="checkbox"
[% 'checked' IF patient.gender.match('F') %] />
Female
<input type="checkbox"
[% 'checked' IF patient.gender.match('U') %]/>
Other / Unknown
</div>
</td>
</tr>
<tr>
<td colspan="2">
<div>NHS number (or postcode if not known)</div>
<div>[% INCLUDE site/nhs_number.tt
nhs_number = patient.nhs_number; %]</div>
</td>
<td>
<div>Presentation status</div>
<div class="small">
<input type="checkbox" /> First diagnosis
<input type="checkbox" /> Recurrence/relapse
<input type="checkbox" /> Unknown
</div>
</td>
</tr>
<tr>
<td class="topAlign" id="additionalInfo" colspan="3">
<div>Additional clinical information (if relevant)</div>
<div class="grey">eg previous tumours, molecular testing,
and relevant treatment history with dates</div>
</td>
</tr>
</table>
<div class="spacer-5"></div>
<table border=0 class="compact">
<tr>
<th colspan="3" class="header">Solid tumour requests only</th>
</tr>
<tr>
<td id="tumourType" rowspan="2">
<div><input type="checkbox" /> Primary</div>
<div><input type="checkbox" /> Metastatic</div>
<div><input type="checkbox" /> Lymphoma</div>
<div><input type="checkbox" /> Unknown</div>
</td>
<td class="topAlign">
<div>Histopathology lab ID</div>
<div class="spacer-5"></div>
</td>
<td class="topAlign" rowspan="2" id="tumourInfo">
<div>Additional tumour information (if relevant)</div>
<div class="grey">eg site of metastasis (if metastatic), or
unknown primary</div>
</td>
</tr>
<tr>
<td>
<div>Date of diagnosis</div>
<div class="grey">dd/mm/yyyy</div>
</td>
</tr>
</table>
<table border=0 class="compact">
<tr>
<th colspan="3" class="header">Haemato-oncology liquid tumour
requests only
</th>
</tr>
<tr>
<td class="topAlign">
<input type="checkbox"
[% 'checked' IF result_summary.match('AML|myeloid') %] />
AML
<input type="checkbox"
[% 'checked' IF result_summary.match('ALL|lymphoblastic') %] />
ALL
<input type="checkbox" /> Other (please specify)
</td>
<td class="topAlign">
<div>Local sample ID</div>
<div>[% UNLESS germline; INCLUDE site/lab_number.tt data = r;
END %]</div>
</td>
<td class="topAlign">
<div>Date of diagnosis</div><div class="grey">dd/mm/yyyy</div>
</td>
</tr>
</table>
<table border=0 class="compact">
<tr>
<th colspan="5" class="header">Complete for tumour samples</th>
</tr>
<tr>
<td colspan="5" class="topAlign">
<input type="checkbox"
[% 'checked' IF sample_dispatched.match('fresh_tissue') %] />
Fresh tissue
<input type="checkbox"
[% 'checked' IF sample_dispatched.match('marrow') %] />
Bone marrow
<input type="checkbox"
[% 'checked' IF sample_dispatched.match('blood') %]/>
Peripheral blood
<input type="checkbox" /> Other (please specify):
</td>
</tr>
<tr>
<td colspan="5">Provide % malignant nuclei / blasts or equivalent
in this sample <span class="grey">(refer to sample handling
guidance)</span>
</td>
</tr>
<tr class="small">
<td>Local sample tube ID</td>
<td>Collection date / time</td>
<td>% malignant nuclei / blasts</td>
<td>nucleated cell count</td>
<td>volume required</td>
</tr>
<tr class="small">
<td><div class="spacer-15"></div></td> <td></td> <td></td>
<td class="grey rightAlign">x10<sup>9</sup>/L</td>
<td class="grey rightAlign">µL</td>
</tr>
<!-- // do we need 2 rows ?
<tr><td><div class="spacer-15"></div></td><td></td><td></td><td></td><td></td></tr>
-->
</table>
<table border=0 class="compact">
<tr>
<th colspan="4" class="header">Complete for germline samples</th>
</tr>
<tr>
<td colspan="4" class="topAlign">
<input type="checkbox"
[% 'checked' IF germline.match('blood') %] /> Peripheral blood
<input type="checkbox"
[% 'checked' IF germline.match('saliva') %] /> Saliva
<input type="checkbox"
[% 'checked' IF germline.match('fibroblast') %] /> Fibroblasts
<input type="checkbox"
[% 'checked' IF germline.match('skin') %] /> Skin biopsy
<input type="checkbox" /> Other (please specify):
</td>
</tr>
<tr>
<td>Local sample ID</td>
<td>Collection date / time</td>
<td>Sample volume if applicable</td>
<td style="width:30%">Comments</td>
</tr>
<tr>
<td>
<div class="spacer-15">[% IF germline;
INCLUDE site/lab_number.tt data = r; END %]
</div>
</td>
<td></td> <td></td> <td></td>
</tr>
</table>
<div class="spacer-5"></div>
<table border=0 class="compact">
<tr>
<th colspan="2" class="header">Consultant details</th>
</tr>
<tr>
<td style="width:45%" class="topAlign">
<div>Responsible consultant:
[% r.referrer_department.referrer.name %]
</div>
<div>Department:
[% r.referrer_department.hospital_department.display_name %]
</div>
<div>Phone:</div>
<div>Email:</div>
</td>
<td>
<div>Main contact (if different from responsible consultant)</div>
<div>Name:</div>
<div>Department:</div>
<div>Phone:</div>
<div>Email:</div>
</td>
</tr>
</table>
<div class="spacer-15"></div>
<div class="indent"><input type="checkbox" />
I have attached a copy of the Record of Discussion form
</div>
<div class="indent"><input type="checkbox" />
Patient conversation taken place, Record of Discussion form to follow
</div>
</div>
<!-- page 2 -->
<div class="wgs">
<table border=0>
<tr>
<th class="borderless">
[% patient.first_name.ucfirst %] [% patient.last_name.upper %]
:: [% patient.dob.dmy('/') %]
:: [% patient.nhs_number OR r.patient_case.unit_number %]
(page 2 of 2)
</th>
</tr>
</table>
<h4 class="indent">Ethnicity - Please tick the relevant self defined
ethnicity code below</h4>
<table border=0 class="compact">
<tr class="header">
<th>White</th>
<th>Mixed</th>
<th>Asian or Asian British</th>
<th>Black or Black British</th>
<th>Other Ethnic Group</th>
</tr>
<tr>
<td>A <input type="checkbox" /> British</td>
<td>D <input type="checkbox" /> White and Black Caribbean </td>
<td>H <input type="checkbox" /> Indian</td>
<td>M <input type="checkbox" /> Caribbean</td>
<td>R <input type="checkbox" /> Chinese </td>
</tr>
<tr>
<td>B <input type="checkbox" /> Irish</td>
<td>E <input type="checkbox" /> White and Black African</td>
<td>I <input type="checkbox" /> Pakistani</td>
<td>N <input type="checkbox" /> African</td>
<td>S <input type="checkbox" /> Any other ethnic group</td>
</tr>
<tr>
<td>C <input type="checkbox" /> Any other White background</td>
<td>F <input type="checkbox" /> White and Asian</td>
<td>J <input type="checkbox" /> Bangladeshi</td>
<td>O <input type="checkbox" /> Any other Black background</td>
<td></td>
</tr>
<tr>
<td></td>
<td>G <input type="checkbox" /> Any other mixed background</td>
<td>L <input type="checkbox" /> Any other Asian background</td>
<td></td>
<td>Z <input type="checkbox" /> Not stated</td>
</tr>
</table>
<h5>Additional local identifiers - please use the table below, these
will also be displayed in the interpretation panel</h5>
<table border=0 class="compact">
<tr class="header">
<th colspan="3">Type - O (Test order/Case ID), P (local
patient ID), S (local sample identifier)
</th>
</tr>
<tr class="header">
<th>Organisation</th>
<th>Type</th>
<th>Identifier</th>
</tr>
<tr> <td><div class="spacer-15"></div></td> <td></td> <td></td> </tr>
<tr> <td><div class="spacer-15"></div></td> <td></td> <td></td> </tr>
<tr> <td><div class="spacer-15"></div></td> <td></td> <td></td> </tr>
<tr> <td><div class="spacer-15"></div></td> <td></td> <td></td> </tr>
<tr> <td><div class="spacer-15"></div></td> <td></td> <td></td> </tr>
<tr> <td><div class="spacer-15"></div></td> <td></td> <td></td> </tr>
</table>
</div>
[% END; ELSE # no requests: %]
<h3 class="indent info">No outstanding WGS requests</h3>
<p class="indent">[% site.html.back_button %]</p>
[% END %]
</body>
</html>
<!-- END [% template.name %] -->