Hypertrophic Cardiomyopathy Pre-referral form
Please send 10mls of EDTA blood or DNA to: Molecular Genetics Laboratory, The Churchill Hospital, Headington, OXFORD, OX3 7LJ.
Contact: Clinical:
Dr Ed Blair
Ed.Blair@orh.nhs.uk
01865 226008
Laboratory: Kate Thomson Kate.Thomson’orh.nhs.uk
01865 225586
Referrals will only be accepted from the following:
REFERRER
PLEASE SELECT
Consultant Clinical Geneticist
Consultant Cardiologist from Cardiovascular Genetics Unit in liaison with a Clinical
Geneticist (N.B. A copy of results reports will be issued to a Clinical Geneticist, please provide contact details below)
Consultant Pathologist in liaison with a Clinical Genetics Department
(N.B. A copy of results reports will be issued to a Clinical Geneticist, please provide contact details below)
Coroner
Minimum criteria required for testing:
CRITERIA
PLEASE SELECT
Individuals who fulfill conventional diagnostic criteria for HCM (ante-mortem or post-mortem)
If the sample does not fulfill these criteria and you still feel that testing should be performed
please contact Dr Ed Blair (details above) to discuss testing of the sample.
Referral Details:
REFERRER DETAILS 1
Name:
Address for report: -
Specialty: - (please circle)
Genetics
Cardiology
Post code: Address for Invoice:
Post code: Telephone: -
Fax No: -
E-mail: -
REFERRER DETAILS 2
Name:
Address for report: -
Specialty: - (please circle)
Genetics
Cardiology
Post code: Address for Invoice:
Post code: Telephone: -
Fax No: -
E-mail: -
P:\Specialist Services\UKGTN\Gene Dossiers\GDs 2007-2008 comm cycle\testing criteria for 0708 comm cycle\Testing criteri - Oxford HCM Clinical
Questionnaire UKGTN Version.doc
Page 1 of 2
Patient Details:
Forename:
D.O.B: Address: -
Surname: NHS No.:
Your Ref. No.: Post Code: -
Additional Information: -
SUMMARY OF CLINICAL INVESTIGATIONS
ECG
Normal
Abnormal
Echocardiogram
Maximum LV wall thickness (cm)
Asymmetric Left Ventricular Hypertrophy
SAM of mitral valve
Diastolic dysfunction
Histology (if available)
Myocardial disarray
FAMILY HISTORY DETAILS
Is there a Family history of: HCM
Sudden Death
CCF
Stroke
Pedigree Details (please state name and D.O.B where known)
In submitting this sample the clinician confirms that genetic counseling has been undertaken and
consent for testing has been obtained.
P:\Specialist Services\UKGTN\Gene Dossiers\GDs 2007-2008 comm cycle\testing criteria for 0708 comm cycle\Testing criteri - Oxford HCM Clinical
Questionnaire UKGTN Version.doc
Page 2 of 2