Title: INHEALTH
Author: Christina.Fromont
Last saved by: Caroline Meechan
Company: InHealth Ltd

Wandsworth CCG
PHYSIOLOGICAL MEASUREMENT REFERRAL FORM
(INCLUDING ECHOCARDIOGRAPHY)
Please note – we are unable to accept referrals for patients under 18 years of age
PATIENT | REFERRER
NHS Number | ~[NHS Number] | Name | ~[Free Text:Referring GP Fullname]
Forename | ~[Forename] | GMC/HPC/NMC No |

Surname

~[Surname]

Address

~[Surgery Address Line 1]
~[Surgery Address Line 2]
~[Surgery Address Line 3]
~[Surgery Address Line 4]
~[Surgery Address Line 5]

Address

~[Patient Address Block]
~[Post Code]

Date of Birth | ~[Date Of Birth] | Referring PCT Code |
Telephone (Home) | ~[Telephone Number] | Referring Practice Code |
Telephone (Work) | | Telephone No. (for urgent clinical findings) | ~[Surgery Tel No.]
Telephone (Mobile) | ~[Mobile Phone Number] | Fax No. |
E-mail Address | | NHS.net mail only |

Gender

~[Sex]

Eligible for and does require NHS funded transport?
(car transport only)                         Yes ☐

Physical/Communication difficulties (specify if any): | Wheelchair user?                              Yes ☐
If interpreter required, language: | The patient must be ambulant, or if a wheelchair user they must be able to transfer independently onto the examination couch.
Ethnicity: ~[Ethnicity] |

CLINICAL INDICATION/PROBLEM
Please provide as much relevant clinical information as possible to ensure the most appropriate investigation is performed.
     

Date of referral: ~[Today...]

Relevant Past Medical History
Cardiac History: | Other Significant History
☐ | MI | ☐ | Hypertension
☐ | Angina | ☐ | Diabetes
☐ | Valve Problems | ☐ | Thyroid Disease
☐ | Murmurs | ☐ | Alcohol/Drug Abuse
☐ | Cardiac Surgery | ☐ | Chronic Anaemia
☐ | Atrial Fibrillation | ☐ | COPD
☐ | Cardiomyopathy | ☐ | Other:
☐ | Pacemaker (If ECG test requested please include details of the pacemaker and pacing centre):
Is the patient currently taking any of the following medication?

☐

☐

Beta Blockers

☐

Sympathomimetics

☐ | Diuretics | ☐ | Anticoagulants
☐ | Anti-arrhythmics | ☐ | Anti-hypertensives
Investigation(s) Required
Echocardiography | ECG | Ambulatory ECG | Ambulatory BP
☐    Full | ☐    12 Lead, Resting | ☐     24 Hour | ☐    24 Hour
| | ☐     48 Hour |

Please post, fax or e-mail this form to the InHealth Patient Referral Centre:
Sandbrook House, Sandbrook Way, Rochdale OL11 1RY
Tel: 0333 202 0297 Fax: 0333 200 1163 E-mail: inl.inhealthreferrals@nhs.net

www.inhealthgroup.com

EMIS LV:  July 2016