NHS Kensington and Chelsea
GP ECHO AND HEART FAILURE

PATIENT DETAILS	GP DETAILS	
Name	«PATIENT_Forename1» «PATIENT_Surname»	Name	«PATIENT_Registered_GP»	
Date of Birth	«PATIENT_Date_of_Birth»	Surgery	«PRACTICE_Name»	
Address	«PATIENT_BlockAddress»	Address	«PRACTICE_BlockAddress»	
Telephone	«PATIENT_Main_Comm_No »	Telephone	«PRACTICE_Main_Comm_No»	
NHS Number	«PATIENT_Current_NHS_Number»	Date of Referral	«SYSTEM_Date»	
Service requested (please tick one)
 Echocardiography only (St Mary’s & C&W)

 Echocardiography and ECG (St Mary’s only)

	Reason for Echo
 Shortness of Breath

 Atrial Fibrillation

 New onset heart failure	
 Peripheral oedema

 Uninvestigated murmur

Other      	
Priority of referral
 High Priority (to be seen ASAP)   Normal Priority (routine)	
	
Clinical Symptoms/signs
 Unexplained breathlessness

 Unexplained oedema

 Heart murmur
		
 Raised JVP

 Pulmonary Crepitations

 Other (please specify)      	
Relevant patient history
 MI specify year      

 Hypertension

 Atrial Fibrillation

 Heart Surgery

 Diabetic	
 Family History Heart Disease

Smoker:  Current (within 2 months)     Past     Never

Number of units of alcohol per week:      

Other relevant condition (please specify):      	
Medication (tick as applicable)
 ACE inhibitor

 Beta Blocker

 Diuretic

 Other Relevant	Drug Name
     

     

     

     	Dose
     

     

     

     	Frequency
     

     

     

     	
Results of previous tests and investigations
Has the patient had an ECG? Yes     No     	If YES were results:   Normal       Abnormal
Has the patient had a CXR?   Yes     No     	If YES were results:   Normal       Abnormal	
Any other relevant information
     	

Please complete this form and FAX it to one of:
Cardiology Department (next to Outpatient Area 4), Level 1			Waller Cardiac Unit, International Centre for Circulatory Health  
Chelsea and Westminster Hospital, 369 Fulham Road			St Mary’s Hospital, Paddington
London SW10 9NH							London W2 1NY
Fax:  (020) 8746 8038	Tel:  (020) 8746 8032			Fax:  (020) 7886 6239		Tel:  (020) 7886 1241	
	
On arrival of this form, your patient will receive an appointment by telephone or by post (please note, this is not a walk in service) 

TO BE COMPLETED BY CARDIOLOGY DEPARTMENT:
DATE OF APPOINTMENT: ____ / ____ / ______                         DID THE PATIENT ATTEND:   YES     NO