Patient Details: GP Details: Name: Name: Address: Address: Postcode: Telephone no: Postcode: Date of Birth: Telephone No: Hospital Unit No: NHS No: Practice Code: Please indicate site preference County/Royal Stoke Please note whilst every effort will be made to accommodate preference this cannot be guaranteed Please circle a yes or no response to every question Exclusion Criteria Has there been a previous diagnosis of coronary disease (angina, MI, PCI or CABG)? Yes / No Has there been a previous diagnosis of significant heart disease including heart failure, Valve disease or cardiomyopathy Yes / No Has the patient undergone assessment or treatment by a cardiologist in the past 5 years Yes / No Presenting symptoms Is the predominant symptom a heavy / tight / constricting discomfort, pain or pressure in the front of the chest, neck, shoulders, jaws or arms? Yes / No Is the symptom precipitated by physical exertion? Yes / No Is the symptom relieved by either rest or GTN in 5-minutes Yes / No Risk factors for coronary artery disease Age? Gender? Male / Female If female, is the patient post-menopausal? Yes / No Is there any history of smoking ? Yes / No Is there a history of diabetes mellitus? Yes / No Is there a history of hyperlipidaemia? Yes / No Is there a history of hypertension? Yes / No Is there a family history of premature coronary disease? Yes / No Is the patient overweight or obese (BMI >27)? Yes / No Signature: Date: ……………………………………………………. ………………………………… Please fax your completed form to the clinic co-ordinator on 08436365239 If you need to speak clinic co-ordinator please telephone 01782 675936 Page 1 of 2
Patient Details: Name: Address: Postcode: Telephone no: Date of Birth: Hospital Unit No: NHS No: GP Details: Name: Address: Postcode: Telephone No: Practice Code: Please indicate site preference County/Royal Stoke Please note whilst every effort will be made to accommodate preference this cannot be guaranteed Please circle a yes or no response to every question Exclusion Criteria Has there been a previous diagnosis of coronary disease (angina, MI, PCI or CABG)? Yes / No Has there been a previous diagnosis of significant heart disease including heart failure, Valve disease or cardiomyopathy Yes / No Has the patient undergone assessment or treatment by a cardiologist in the past 5 years Yes / No Presenting symptoms Is the predominant symptom a heavy / tight / constricting discomfort, pain or pressure in the front of the chest, neck, shoulders, jaws or arms? Yes / No Is the symptom precipitated by physical exertion? Yes / No Is the symptom relieved by either rest or GTN in 5-minutes Yes / No Risk factors for coronary artery disease Age? Gender? Male / Female If female, is the patient post-menopausal? Yes / No Is there any history of smoking ? Yes / No Is there a history of diabetes mellitus? Yes / No Is there a history of hyperlipidaemia? Yes / No Is there a history of hypertension? Yes / No Is there a family history of premature coronary disease? Yes / No Is the patient overweight or obese (BMI >27)? Yes / No Signature: ……………………………………………………. Date: ………………………………… Please fax your completed form to the clinic co-ordinator on 08436365239 If you need to speak clinic co-ordinator please telephone 01782 675936 Page 1 of 2
RACP%20Ref%20form%20%28new%29.docx