TIA / minor stroke clinic referral form
High risk patients (ABCD2≥ 4) at weekends: call JR switch (01865 741166) and ask for the
registrar on call for TIA. Advice: TIA specialist nurse (JR switch, 01865 741166, bleep 6342)
Patient details
Name
Address
DoB
Hospital Number
NHS number
GP Practice
Registered GP
Phone number (+ mobile)
The patient will be contacted a.s.a.p. via these details to make an appointment
Clinical details
Date and time of symptoms
Description of event
Vascular risk factors
Medication (& relevant changes)
ABCD2 score for risk stratification
Age
Age over 60
(1 point)
Blood pressure
SBP>140 or DBP>90mmHg
(1 point)
Clinical features
Unilateral weakness
(2 points)
Speech disturbance without weakness (1 point)
Duration
>60 mins (2 points)
10-59 min (1 point)
Diabetes
Present
(1 point)
Score
Total
Referrer’s name, position and contact details
Date
Source
GP
A&E
Office use TIA or minor stroke
Other
Other (specify)
Same day urgent investigations performed Y
MRI
Fax to
Doppler
N
CT
Becky Louch, Geratology administrator, JR, 01865 234815
Horton fax no 01295 229603
TIA clinic referral form. Depts Geratology & Neurology, John Radcliffe Hospital. June 2011