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RAPID ACCESS CHEST PAIN CLINIC REFERRAL
Patients will be offered the first available appointment within two weeks of
referral.
A resting 12 Lead ECG must accompany all referrals.
Tick to exclude:
 Male age <30, female age <40 (very low probability of ischaemic heart disease)
 History of MI, PTCA, CABG within the last year
 Previous referral to cardiology outpatients or Emergency Department with
angina (refer back to original outpatient team)
 Resting ECG finding of LBBB
 Uncontrolled hypertension (BP <180/110 to allow exercise tolerance test)
 Inability to walk >100 metres at a normal pace
 Clinical evidence of heart failure
 Patients with known or suspected valve disease
If any of the above apply please refer the patient directly to Cardiology Outpatients.
Today’s date
Forename:
Surname:
D.O.B:
Address:
GP Name:
Address:
Fax No:
Contact Tel:
NHS No:
Tel No:
History (Include relevant previous medical history and current symptom history):
Risk Factors (please indicate):
Hypertension:
Y/N
Cholesterol:
Peripheral vascular
disease:
Smoker?
Smoking history:
Y/N
Y/N
BP:
Diabetes:
Diet/Medication/IDDM
Family history of CHD
(<age 55)
Stroke:
/
Y/N
Y/N
Y/N
Resting ECG Findings:
Current Medication:
Signed:
Name (print):
Date:
Please FAX this form to the two week wait bureau; 01865 231407
Additional information can be provided in a separate letter, if necessary