CAR
Cardiac Arrhythmia Pre-referral Form
Page 1: Referral details
Please send 10mls EDTA blood or DNA to: Molecular Genetics Laboratory, The Churchill Hospital, OXFORD, OX3 7LJ
Contact: Clinical:
Dr Ed Blair
E-mail: Ed.Blair@orh.nhs.uk
Tel: 01865 226008
Laboratory: Karen Livesey E-mail: Karen.Livesey@orh.nhs.uk
Tel: 01865 225591
Referrals will only be accepted from the following:
Referrer
Clinical Geneticist
Consultant Electrophysiologist / Cardiologist, in liaison with a Clinical Genetics Department
Results will be reported to Clinical Genetics, please provide contact details in Referral details section below.
Tick if this refers to you
Minimum criteria for testing
Referral category
Criteria
Please select
Autosomal Dominant LQTS
(Romano Ward Syndrome)
Clinical diagnosis or probable clinical diagnosis.
Jervell and Lange Neilsen Syndrome
(Autosomal recessive LQTS & congenital deafness)
Clinical diagnosis or probable clinical diagnosis
Brugada Syndrome
Clinical diagnosis or probable clinical diagnosis
Test for Familial Mutation
Relative of proband with known pathogenic
mutation.
In submitting this sample the clinician confirms that genetic counselling has been provided
and consent for testing has been obtained.
Referral details
Referring
Clinician
E-mail
Address
for Report
Telephone
.
Reference / Case No
Post code
Patient information
Surname
D.O.B.
Forename
NHS No.
Affected
Alive
Cardiac Arrhythmia Pre-referral Form 1
Page 2: Clinical and family history details
Copies of most recent ECG and echocardiogram report attached
Symptoms (please indicate)
ECG
Syncope with physical activity
Rhythm
Syncope with auditory stimuli
QTc interval
Syncope with rest / sleep
Inducible
abnormalities
Pre-syncope
24 hr ECG
Seizures
Non sustained VT
Torsades de Pointes
Palpitation
Echocardiogram
Congenital deafness
Normal
Abnormal
Please specify other ECG and echocardiogram abnormalities
Clinical management: e.g. ICD and details of drugs that may lengthen the QT interval
Family history details
Is there a family history of:
Sudden death (SD)
Long QT syndrome
Blackouts
Brugada Syndrome
Pedigree Details (Please state name and d.o.b where known, also include details of affected family members)
Details of familial mutation
If testing for a familial mutation is required, please provide the following information
Name of mutation (include name of gene)
Name of family member in whom mutation was found
Relationship to this patient
Cardiac Arrhythmia Pre-referral Form 2