GP REFERRAL FORM FOR TIA
PATIENT	REFERRER	
Name	<<Calling Name>> <<Surname>>	Name	<<Forenames>>   <<Surname>>	
NHS Number	<<NHS Number>>	GMC number	<<GMC/HPC No>>	
Patient’s Address	<<Full Address (stacked)>>	Practice Address	<<Full Address (stacked)>>
	
Home /Mobile numbers	<<Home Telephone>>/<<Mobile Telephone>>	Practice Number	<<Phone Number>>
	
Work ‘phone	<<Work Telephone>>	Practice Fax	<<Fax Number>>	
Email address	<<E-mail Address>>	Practice Email	     	
DoB	<<Date of Birth>>	Practice code	<<National Practice Code>>	
Gender	<<Gender>>	PCT code	     	
Interpreter Required	Yes 	No 	Date of Referral	<<Today’s date>>	
Language <<Main Language>>		Ethnicity   <<Ethnic Origin>>	Signature	     	
Carer details – if appropriate	Name and relationship:
     	Address:
     	Phone Number:      	
Date and time of event(s)	                     	Duration of symptoms	      hours       minutes	
Date and time of assessment:                                        	

FAST Test	(Y/N)	ABCD2 Test
Clinical features at time of TIA	Score	
Face
	New unilateral weakness	Y  N
	Age   ≥ 60 = 1
           < 60 = 0		
Arm
	New unilateral weakness	Y  N
			
Speech	New speech disturbance	Y  N	BP     Systolic > 140 and/or Diastolic ≥ 90 = 1
           Other = 0		
FAST is positive when any of the features above are present	Clinical Features
Any unilateral weakness (face/hand/arm/leg) = 2
Speech disturbance without weakness = 1
Other = 0		
NOTE: Not all TIA/strokes are FAST positive. (e.g. patients presenting with ataxia, sensory disturbance, or amaurosis fugax).  If you think the diagnosis remains TIA or stroke, carry on with the protocol.
If the following are present at onset, TIA is unlikely: gradual onset or spread of symptoms; seizure or loss of consciousness; transient amnesia; isolated vertigo.
If any of these are present, consider an alternative referral route.  If in doubt, contact your local stroke team for advice.			
	Duration   ≥ 60 minutes = 2
                   10 – 59 minutes = 1
                    < 10 minutes = 0		
	(Known) Diabetes = 1	
	
	Total Score (range 0 – 7) 
ABCD ≤ 3 = low risk of early stroke      
ABCD ≥ 4 = high risk of early stroke                        		
Brief description of event(s). This is mandatory; without this an appointment cannot be made.
Please include any relevant clinical information not covered elsewhere on the form and current medication*.
      (Limited to 800 characters)

BP:                               Pulse:                      *Tell pt to bring all medication with them to their appointment 	
Risk factors and check list	
Hypertension 	Y N	Previous stroke/TIA 	Y N	Ischaemic heart disease	Y N	AF/PAF	Y
N	Transport needed?	Y N	
Administered aspirin (300 mg) if necessary		Told patient not to drive until assessed at TIA clinic		
Told patient to bring witness to event to the TIA clinic if possible		Told patient to return immediately to A&E if there are any further symptoms		
Please refer to page 2 for information on the TIA referral pathway.

TIA referral pathway

Are symptoms still present?	→ Yes →	ACTION: TREAT AS ACUTE STROKE
1. Complete form to send with patient
2. Call ambulance to send to HASU A&E immediately 
3. Contact stroke team at:
Charing Cross: Stroke SpR 020 3311 1234 Bleep 0383
Northwick Park: 07825 014 789 or 020 8864 3232 Bleep 640 	
↓
↓
No
↓
↓			
			
Was the event within the last 7 days or is patient on Warfarin or are they in AF/PAF?	→ Yes →	Have they had 2 or more events in the last 7 days or are they on Warfarin or are they in AF/PAF?	
↓
↓
No
↓
↓	↓
No
↓	↓
↓
Yes
↓
↓	
	ABCD2 ≥ 4 (high risk group)?		
	↓
No
↓	↓
Yes
↓		
ACTION: TIA clinic referral
1. Complete clinical description
2. Prescribe aspirin 300 mg (unless
    on Warfarin) and give first dose
3. Refer to TIA clinic of preference –
    FAX form (details in box below)		ACTION: URGENT SPECIALIST ASSESSMENT AT TIA CLINIC
1. Complete clinical description
2. Prescribe aspirin 300 mg (unless on Warfarin) and give first  
    dose
3. Mon 9 am to Fri 4 pm, including after 5 pm Mon to Thurs:
    FAX form and phone local stroke team (details in box below). 
    Fri 4 pm – Mon 9 am and Bank Holidays:
    Charing Cross: Stroke SpR 020 3311 1234 Bleep 0383 or 
    Northwick Park: 07825 014 789 or 020 8864 3232 Bleep 640	

Contact details of TIA clinics in NW London	
Hospital	
Weekdays/ Enquiries
	
Weekday evenings
	
Charing Cross
FAX: 020 3313 3848
	020 3311 1234
1.Stroke SpR Bleep 0383
2.CNS Bleep 0384
	Stroke SpR
020 3311 1234 Bleep 0383
	
Chelsea and Westminster
FAX: 020 3315 6528
	Stroke Coordinator
07816 445 068 or
020 8746 8000 Bleep 0385
	Stroke SpR
07816 445 068 or
020 8746 8000 Bleep 0385	
Hillingdon
FAX: 01895 279464	Stroke Specialist Nurse
077 0423 5209 or
01895 238282 Bleep 5447
	Medical SpR 
01895 238282 Bleep 5808	
Northwick Park
FAX: 020 8869 2241	Stroke Coordinator 
07789 500 156 or
020 8864 3232 Bleep 634
	Stroke Specialist Nurse
07825 014 789 or
020 8864 3232 Bleep 640	
St Mary’s
FAX: 020 3312 1698	020 3312 6666
Stroke SpR Bleep 1693
	Call CXH 020 3311 1234 Bleep Stroke SpR 0383	
West Middlesex
FAX: 020 8321 5270
	Stroke Specialist Nurse
020 8560 2121 Bleep 413 or
stroke SpR Bleep 188
Please ring for an appointment before patient leaves your surgery, and fax referral	Fax referral.
Please ask patient to call
020 8321 5919 the following morning at 9.00 to confirm appointment.