Cardiac Physiologist Ambulatory Monitoring Service Referrral

GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST

CARDIAC PHYSIOLOGIST AMBULATORY MONITORING SERVICE

Patient Patient Surname: First Name:

Address: NHS Number (New)

Hospital No:

Date of Birth D D M M Y Y Y Y / / Male Female

Postcode: Telephone Number:

Date of Decision to Refer by GP: Referring D D M M Y Y Y Y GP:

Registered or Practice Usual GP: Code:

GP Telephone Number:

Exclusions Patients with current arrhythmias who are clinically/Haemodynamically compromised should be admitted in the normal manor. Patients with known established/ diagnosed arrhythmias should only be referred as long as they are no longer under active follow-up for this arrhythmia and where there has been a significant change.

YES must be ticked to all questions in order to access the TLPC

1 – Does the patient have a history of palpitations YES NO

3 – Is the patient suitable for an Ambulatory Monitor? YES NO

Clinical Details, e.g. Characteristics/frequency of palpitations and any associated symptoms, please list below: PLEASE ATTACH CURRENT MEDICATION: ………………………………………………………………………… ………………………………………………………………………… ……………………………………………………………… ………………………………………………………………………… ……………………………………………………………… ………………………………………………………………………… ………………………………………………………………………… ……………………………………………………………… ………………………………………………………………………… ……………………………………………………………… ………………………………………………………………………… ………………………………………………………………………… …………………………………………………………… This communication and any documents following are confidential and may be privileged from disclosure. If you receive this communication in error, please telephone (01242) CONFIDENTIAL 223561 For further information & guidance, please contact Paula Smith OR Helen Mock on: GRH 0300 422 8281 CGH 0300 422 3561

As at 07.03.2016