Dilated 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
Individual who fulfills conventional diagnostic criteria for Idiopathic DCM with at least:
one first or second-degree relative also diagnosed with Idiopathic DCM
or
one first-degree relative with an unexplained sudden death under the age of 40 years
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: -
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Questionnaire UKGTN Version.doc
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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
LVEDD(cm)
LVESD (cm)
Ejection fraction
Differential diagnoses excluded (please tick if excluded)
Coronary artery disease
Myocarditis
High blood pressure
History of alcohol abuse
Cor pulmonale
Other genetic conditions investigated/excluded (eg. Haemochromatosis)
FAMILY HISTORY DETAILS
Is there a Family history of: Sudden Death
DCM
HCM
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.
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