Open access Echocardiology and Heart Failure
Cardiology Department
Patient Details
Name
Date of Birth
Sex
Address
Male
General Practitioner Detail (or stamp)
Name
Surgery
Address
Female
Postcode
Telephone
NHS Number
Telephone
Fax
DATE OF
REFERRAL
Service Requested
Echocardiogram
New onset heart failure
Priority of referral (please tick one
High priority (to be seen A.S.A.P)
Low Priority (within 4-6 weeks)
Clinical Symptoms/Signs
Pulmonary crepitations
Raised JVP
Other (please specify)
Unexplained breathlessness
Unexplained oedema
Heart murmur
Relevant Patient History
(Year?
)
Smoker
Number of units
of alcohol per
week:
Other relevant
condition (please
specify)
MI
Hypertension
Atrial fibrillation
Heart surgery
Murmurs
Diabetic
Family history of
heart disease
Medication (please tick)
ACE Inhibitor
Diuretics
Other
Name
Current
Past
Never
Date
Results of previous Tests and Investigations
Has the patient had an ECG?
Yes
No
If Yes, were the results:
Normal?
Has the patient had a chest x-ray?
Yes
If YES, were the results
Normal?
Abnormal?
No
Abnormal?
Any other relevant information:
Please complete this form and return it to:
Cardiology Department (next to Outpatient Area 4), First Floor,
Chelsea and Westminster Hospital, 369 Fulham Road, SW1O 9NH
Telephone: 020 8746 8032 Fax: 020 8746 8038
TO BE COMPLETED BY CARDIOLOGY DEPARTMENT:
DATE OF APPOINTMENT:
DID PATENT ATTEND? YES
NO
On arrival of this form, your patient will receive an appointment by telephone or by post (Note: this is not a walk-in service)