Diagnostic Testing Unit Clinic G, Podium 1 University College Hospital 235 Euston Road London NW1 2BU |
Telephone: 0845 1555 000 Ext 73120 Direct dial: 0203 447 3120 Website: www.uclh.nhs.uk |
Request for Cardiac Investigation
PATIENT DETAILS |
GP DETAILS |
Title |
Name |
Surname |
Surgery |
Forename |
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Hospital No |
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DOB |
Fax |
Ward/Dept |
Name referring GP if different from above |
Consultant |
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Address |
GP Signature |
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Telephone |
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SERVICE REQUESTED |
CURRENT MEDICATIONS |
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Routine ECG ( restricted opening time) see below |
Transthoracic Echocardiogram |
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24 Hour Tape |
24 Hour Blood Pressure |
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PRESENTING SYMPTOMS |
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Chest pain |
Oedema |
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Shortness of Breath |
Syncope |
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Recurrent Palpitations |
PND/Orthopnoea |
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Other: |
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WHAT QUESTION DO YOU WANT ANSWERED BY THIS TEST? |
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CLINICAL DETAILS |
ALLERGIES: NKDA |
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Cardiac Investigations Request Form notes
12 Lead ECG ( walk-in service with restricted opening time) Opening times: Tuesday: 13:30-16:45, Wednesday: 09:00-16:45 and Thursday: 13:30-16:45
Transthoracic Echocardiogram Indications: For suspected heart failure with an abnormal BNP (please input value below) or ECG (please attach) BNP:_______ New atrial fibrillation or atrial flutter 'once heart rate controlled e.g. once mostly <100bpm at rest Suspected angina Known hypertension ( no previous echocardiogram )
24 hr holter monitoring Indications: Syncope or pre syncope Recurrent palpitations
Investigations are carried out at UCLH. Patients will be provided with clear instructions with their appointment Please complete ALL sections of the form legibly and email to [email protected] The department is open 09:00-17:00 Monday to Friday and some adhoc weekends. Please remember that incomplete forms result in delays to service and inadequate reporting.
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Tags: clinic g,, diagnostic, university, testing, podium, college, clinic