Community Heart Failure Service: Clinic Referral Form
Patient Name:
GP:
DOB:
Phone:
NHS No:
Practice Address:
Address:
Ethnicity
Tel:
Tel:
Reason for
Referral (Tick)
Education
Medication Titration
Support post discharge and Medication review
Unstable heart failure , new diagnosis
Please circle
NYHA status
Class 1
Past Medical
History:
Please provide a copy of latest Echo report and blood tests
You may submit your own referral letter/patient summary provided it contains the information
requested.
Class 2
Class 3
Class 4
Current Medication (attach printout if preferred)
Allergies:
Main Carer:
Relationship:
Signature/print of referrer:
Tel:
Position:
Date of Referral:
NYHA Classification of Heart Failure
Class
Patient Symptoms
Class I (Mild)
No limitation of physical activity. Ordinary physical activity does not cause undue
fatigue, palpitation, or dyspnoea (shortness of breath).
Class II (Mild)
Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity
results in fatigue, palpitation, or dyspnoea.
Class III (Moderate)
Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity
causes fatigue, palpitation, or dyspnoea.
Class IV (Severe)
Unable to carry out any physical activity without discomfort. Symptoms of cardiac
insufficiency at rest. If any physical activity is undertaken, discomfort is increased.
Referral Guidelines for Community Heart Failure Team
Inclusion criteria

Patients must have diagnosis of left ventricular systolic dysfunction with objective evidence such as Echo or angiography.

Main clinical problem of symptomatic heart failure.

Patients who are symptomatic and are diagnosed as having preserved systolic function

Client approves of the referral and is able to provide own transport
Please fax referral to Heart Failure Nurses on 020 7792 7736. If the referral is urgent you will also need to ring the nurses on the
same number.
CHSSC/LM/CLCH/v1.08/12