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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