CARDIOLOGY REFERRAL FORM
Patient Name:
Referring Doctor:
Patient D.O.B:
Patient UR:
Cardiology Specialists:
Dr Raibhan Yadav
Dr Dharmesh Anand
Dr Robert Tam
Yes
No
Cardiac Surgery Specialists:
Pre-Requisite Tests Completed
Diagnosis:
Dr Sugeet Baveja
Dr Ryan Schrale
Dr Sumit Yadav
Dr Kumar Gunwardane
Dr Dong Kang
Other Management or Medications Trialled:
Reason for Referral:
Angina/chest pain
Syncope/Presyncope
Cardiac Murmur
SOB/Orthopnea/PND
Arrhythmia
Heart Failure
Routine follow up
Preoperative cardiac eval.
Optimisation of medications
OR
Abnormal test results
Pathology
Tests Only:
Pacemaker Check
Holter
Echo
Exercise ECG
FBC
LFTs
INR stable
(conditions apply see Referral Guidelines Booklet)
U&E
Yes
BSL
HbA1c
Lipids
No
Can use a tread mill
Comments:
ECG
Duration of Symptoms & Urgency:
Imaging and Other Tests
Cardiac Risk Factors:
FHx
Diabetes
Lipids
Smoker
Hypertension
Achievable Level of Exertion for Stress Testing Only
Walk briskly or run 1km
Walk slow pace 500m
Climb a flight of stairs easily
Can walk________________mtrs with ease
New York Heart Association (NYHA)
Classification
No limit of activity. No symptoms from
Class I.
ordinary activity
Mild limitiation of activity. Comfortable
Class II.
at rest with mild exertion
Marked limitation of activity.
Class III.
Comfortable only at rest
Any physical activity causes
Class IV.
discomfort; confined to bed or chair
and symptoms occur at rest.
GP Signature:
Date:
Please complete & fax to TTH on FAX: 4433 1221,
ALONG WITH the following:
1. Patient Information Form OR Referral Letter
2. ALL RESULTS
Refer EMERGENCY conditions to the ED. & Telephone ED
Registrar 4433 2916
Version updated last: 19/09/2013