Referral Form – VASCULAR
Patient Name:
Patient D.O.B.:
Patient Address:
Home Phone:
Mobile Phone:
Referring Doctor:
Referral to:
Patient UR:
Prof Jon Golledge
Dr Ramesh Velu
Dr Nile Allaf
Any of the selected specialists or their nominated locum
Interpreter required?
Language (please specify) _______________________________
Provisional Diagnosis:
___________________________________________
Varicose Veins
Venous Ulcers
skin changes
___________________________________________
Superficial Thrombophlebitis
bleeding
DVT, Site:__________________
Pre-Requisite Tests
Completed
Reason for Referral:
Yes
No
Including 1. Duration and severity of symptoms
2. Functional deficits and effect of ADL
___________________________________________
___________________________________________
Fitness For Surgery - American Society of Anaesthesiologists
(ASA) physical status classification:
I.
II.
III.
___________________________________________
___________________________________________
IV.
Healthy patient
Mild systemic disease with no functional
limitation - for example, controlled
hypertension
Severe systemic disease with definite
functional limitation - for example,
chronic obstructive pulmonary disease
Severe systemic disease that is a
constant threat to life - for example,
unstable angina
Peripheral Artery Disease
Intermittent Claudication
Definition: “The onset of pain in a muscle group of the lower
leg that worsens with exertion”
Significant Results:
Imaging:
Rest Pain
Definition: “Pain present in the foot every night for three to
four weeks”
U/S Carotid
CT
Pathology:
Ischemic Ulcer
All patients:
BSL, Lipids, U&E, FBC, HbA1c
Gangrene
Other:
Carotid Artery Disease
TIA focal event with complete recovery
Stroke with good recovery
Amaurosis fugax
Aortic Aneurysm
Transverse Diameter ______mm
(>50mm requires URGENT referral)
On Examination (additional findings):
ABPI:__________
GP Signature:
Date:
Please complete this form and fax to TTH on Fax: 4433 2810, ALONG WITH:
1. Patient Information Form OR Referral Letter
2. ALL RESULTS
Refer EMERGENCY Conditions to TTH Emergency Dept. + Telephone ED Registrar – Ph. 4433 2916.
(Version updated 14/06/2012)