<p> GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST</p><p>CARDIAC PHYSIOLOGIST AMBULATORY MONITORING SERVICE</p><p>Patient Patient Surname: First Name:</p><p>Address: NHS Number (New)</p><p>Hospital No:</p><p>Date of Birth D D M M Y Y Y Y / / Male Female</p><p>Postcode: Telephone Number:</p><p>Date of Decision to Refer by GP: Referring D D M M Y Y Y Y GP:</p><p>Registered or Practice Usual GP: Code:</p><p>GP Telephone Number:</p><p>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.</p><p>YES must be ticked to all questions in order to access the TLPC</p><p>1 – Does the patient have a history of palpitations YES NO </p><p>3 – Is the patient suitable for an Ambulatory Monitor? YES NO</p><p>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</p><p>As at 07.03.2016</p>