Cardiac Physiology Measurement Test Request
ALARM SYMPTOMS: Patient with these symptoms should be referred to hospital as stated:
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True unstable angina/suspected MI - phone 999 and admit CCU
Recurrent sudden loss of consciousness without warning (syncope) - urgent referral
New onset/worsening cardiac chest pain – refer to Rapid Access Chest Pain Clinic
New onset heart failure with elevated BNP – refer to Rapid Access Heart Failure Clinic
Patient Details
Name: «PATIENT_Forename1» «PATIENT_Surname»
Email Address:
First Language:
Address:
«PATIENT_BlockAddress»
GP Details
GP Name:
Address:
«REFERRAL_Clinician»
«PRACTICE_Name»
«PRACTICE_BlockAddress»
Date of Birth: «PATIENT_Date_of_Birth»
Gender:
«PATIENT_Sex»
Ethnicity:
Interpreter Required:
Tel (Daytime): «PATIENT_Main_Comm_No»
Tel (Work):
Tel (Mobile):
NHS No:
«PATIENT_Current_NHS_Number»
Hospital No:
Tel No:
«PRACTICE_Main_Comm_No»
Fax No:
Date of referral: «SYSTEM_Date»
Practice Code:
Test Request
Direct access Cardiology diagnostic appointments are for patients that only need a single test
(not a range of diagnostic tests and clinical assessment – please referral to general clinics).
For Choose and Book use Speciality – “Diagnostic Physiological Measurement”
24 Hour ECG [Cardiac Test (Not Echo) on CaB]
Echocardiogram [Echocardiography on CaB]
24 Hours Blood Pressure Monitoring [BP Monitoring on CaB]
Does the patient have an infection or risk to others? (tick if yes)
Clinical question you want the test to answer? (mandatory):
Please attach list of current medication & relevant past medical history
Allergies
«DRUG_ALLERGY»
Current Medication:
«REPEATS»
Other Relevant Medical History:
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«PATIENT_Forename1» «PATIENT_Surname» «PATIENT_Current_NHS_Number»