Rapid Access Chest Pain Clinic Referral Form
Consultant: Dr M E Speechly-Dick Website: www.uclh.nhs.uk/racpc
RACPC co-ordinator direct line: 020 3456 6000
Referral criteria: new or recent onset of EXERTIONAL chest pain suggestive of ischaemic heart disease
(IHD) or worsening symptoms in a patent with known IHD who is not under active follow-up by a
cardiologist. Please complete form and fax to 020 3456 6247
Patient details
GP details
Name
Sex
d.o.b.
NHS Number
Hosp. Number
Address
GP name
Practice name
Practice address
Postcode
Telephone
Telephone
Interpreter needed YES/NO
History of chest pain/discomfort
______________________________________________________________
______________________________________________________________
______________________________________________________________
score
Position on chest
Front of the chest/neck/shoulders/jaw/arms
Right-side/sub-mammary/epigastric/very localised
1
0
Type of pain
Constricting/Cramping
Stabbing/Sharp/Burning
1
0
Precipitating factor
Always a consistent level of exertion, relieved by rest 1
Both at rest and exertion
Nothing in particular/unpredictable
Breathing in/out
0
0
0
5-15 minutes
Seconds/couple of minutes
More than 15 minutes to hours
1
0
0
Duration of episodes
If score is 3-4
this may represent angina – REFER
If score is 2
see risk factor score below - if risk factors score ≥1, REFER – otherwise, treat risk factors using
primary prevention risk calculator http://www.qrisk.org
If score is 0-1
it is unlikely to be stable angina – consider alternative cause for chest pain, do not refer; if risk
factors score ≥1, treat risk factors http://www.qrisk.org
Risk factors
score
Diabetes mellitus
1
Cholesterol > 6.47
1
Smoking
1
Consider family history of a first-degree relative of premature coronary disease, hypertension and BMI>25 as
other risk factors
Past history of IHD? Yes/No
Clinical examination and investigation
Murmur Yes/No
Known AF Yes/No
Anaemic Yes/No
Cholesterol
BP
HDL
ECG Normal/Abnormal