Download Rapid Access Chest Pain Clinic - St Helens and Knowsley Teaching

Rapid Access Chest Pain Clinic Referral Form
This service is available via Choose & Book or the form can be faxed to the
CARDIO-RESPIRATORY DEPARTMENT at WHISTON HOSPITAL within 24 hours of
completion (Fax. 0151 430 1889)
Incomplete request forms and inappropriate referrals will be returned which may
result in a delay for the patient
Name:
GP:
Address:
Address:
Post Code:
Post Code:
Tel No:
Tel No:
Mobile No:
Fax No:
Date of Birth:
NHS No:
Signed:
Date:
This clinic is for patients with a suspected NEW ONSET OF ANGINA PECTORIS ONLY.
Patients with unstable angina or suspected myocardial infarction must be referred to the
Accident & Emergency Department in the usual way.
If your patient has worsening angina, has had a previous myocardial infarction or undergone angioplasty or
cardiac surgery, then please refer to General Cardiology Clinic as an urgent referral.
1. Symptom Pattern [ please tick as appropriate ]
1.
2.
3.
4.
5.
6.
Precipitated by exercise.
Retrosternal location.
Radiation to jaw, left arm or neck.
Brief duration.
Relieved promptly by rest or GTN.
Absence of other causes of chest pain
Known infection risk: eg. MRSA, Hep B or HIV
BP ____ / _____ mmHg
Cholesterol [ if known] _______ mmol/l
Please enclose ECG with request if available
Yes / No
2. Current Relevant Medication [ please list ]
CRD/CH/JB/AJT/Ver 3 - May 2010