Download Patient First Name: «PATIENT_Forename1» Surname

Patient First
Name:
DOB:
Ethnicity:
«PATIENT_Forename1»
Surname:
«PATIENT_Date_of_Birth»
----------------------
Sex:
NHS No:
House No. /
Name:
Street:
City:
«PATIENT_House»
«PATIENT_Road»
«PATIENT_Locality»,
«PATIENT_Town»
«PATIENT_Postcode»
«PATIENT_Main_Comm_No»
«PATIENT_Mobile_No»
Post Code:
Home Phone
No:
Emergency
Contact
Name:
Relation To
Contact:
Emergency
Contact
Phone
Any Special Requirements:
«PATIENT_Surname»
Referral «SYSTEM_Date»
Date:
«PATIENT_Sex»
Preferred Leisure Centre:
Vale Of Neath Leisure
«PATIENT_Current_NHS_Number»
Centre
Referrers Details:
Referrer Name: «REFERRAL_Clinician»
Profession: «REFERRAL_Department»
Address: «PRACTICE_House» «PRACTICE_Road»,
«PRACTICE_Locality»,
«PRACTICE_Town», «PRACTICE_County»,
«PRACTICE_Postcode».
Usual GP: «PATIENT_Usual_GP»
Practice: «PRACTICE_Name»
Date of Most Recent Cardiac Event:
Details:
Cardiac History Prior To Event
Angina / Arrhythmia History
No Previous Heart History
Current Angina?
STEMI
Date of onset:
NSTEMI
Details of angina:
Unstable angina
Triggers:
Stable angina
Complications:
Yes
No
Relieved by rest or GTN:
Yes
No
CABG
Arrhythmias:
Yes
No
Primary/Elective PCI
Date of onset:
Yes
No
Cardiac arrest
Details of arrhythmias:
Valve repair/replacement
ICD/Pacemaker date fitted:
NYHA Classification
1
Ejection fraction (if known)
2
3
4
Details/Settings:
Medication (please tick all currently taken)
Aspirin
Clopidogrel/Prasugrel
Lipid Lowering Statin
Beta Blocker
Ivabradine
Alpha Blocker
Insulin
Significant side effect causing problems:
Investigations
ECG ETT
Yes
Full:
No
Modified:
Ace Inhibitor
Angiotensin ii Receptor Blocker
Nitrate
GTN Spray/Tablets
Calcium Channel Blocker
Anti-Arrhythmic
Other Medications:
Pottasium Channel Activators
Diuretic
Warfarin
Frequency of GT use
Name
Specify Type
Echocardiogram
Angiogram
Yes
No
Date:
Date:
Date:
Result:
Yes
Result:
+ve
-ve
LV Function: Good
Moderate
Poor
Not known
Stage reached: METS
Treatment
planned:
Reason for
Termination:
Co-morbidities that may contraindicate or restrict exercise or ADL’s
Stroke
Neurological
COPD/Asthma
Claudication
MSK/ Joint Replacement
Epilepsy
Other
Details:
CHD Risk Factors (please tick all applicable)
Smoker : Yes
No
Diabetes:
Type 1
Excess Alcohol:
Ex
Type 2
Blood Pressure: «PATIENT_BP»
High Cholesterol
Hypertension
FH of CVD
Physical inactivity pre Phase III
Stress affecting health
Waist Circumference:
Resting Heart Rate:
BMI: «PATIENT_BMI»
No
Rehabilitation Exercise Status
Date started:
Pre exercise BP final session:
Date completed:
Pre exercise HR final session:
Number of sessions attended:
Prescribed training HR range:
Type:
Circuit
Gym
Achieved training heart rate:
Total CV time achieved
mins. per CV station:
Average RPE:
Interval:
AR Time
Approx METS achieved if known:
Continuous:
Home exercises/activities:
Able to self pace:
Yes
No
Adaptations/Limitations:
Cardiac symptoms during exercise:
Yes
No
Frequency
Intensity
Time
Type
Please specify:
Long term Management Use Only
Risk stratification: High
Moderate
Prescribed Training HR Range:
Low
Exercise Considerations:
Personal Goals:
Patient Informed Consent: This scheme has been fully explained to me. I wish to increase my current activity levels
by participating in this scheme. I give consent for any relevant clinical information about my health and participation
on this scheme to be used for evaluation and monitoring purposes. I consent to my information being stored on a
secure database.
I agree to this referral, and am prepared to attend 2 regular exercise sessions weekly.
Patients name please print: «PATIENT_Forename1» «PATIENT_Surname» Date: «SYSTEM_Date»
Patient’s Signature:__________________________________________________________________
GP/AHP Consent: I confirm that the patient does not have any of the exclusion criteria as indicated below:









Unstable angina new angina (diagnosed within the previous month) or a change in the pattern of
established angina.
Unstable or acute heart failure, fluid retention evidenced by excessive breathlessness, rapid weight gain
swollen ankles and pitting oedema.
Unstable diabetes, change in pattern and or treatment, blood sugar level>13.
Uncontrolled arrhythmias
Uncontrolled tachycardia
Uncontrolled hypertension >180/100 (in either)
Symptomatic hypotension
Febrile illness
Awaiting further cardiac investigation
NONE PRESENT
(TICK TO CONFIRM)
(Absolute contraindications adapted from BACR (2009) Phase IV Exercise Instructor Training Manual & ACSM (2009) Guidelines
for Exercise Testing and Prescription)
I refer this patient in accordance with the guidelines of the scheme, which I have received read and understood. At
the time of referral this client was clinically stable, compliant with prescribed medication, is not awaiting any further
cardiology investigations or treatments. If I become aware of their condition (s) changing in a way that would affect
the client’s ability to exercise I will inform the scheme co-ordinator as soon as reasonably possible.
Referrers name please print: «REFERRAL_Clinician»
Date: «SYSTEM_Date»
Signature:_____________________________________________________________________
Please attach any further information to this form before sending