CHEST PAIN CLINIC REFERRAL FORM
Please complete all sections and attach 12 lead ECG
Referral criteria (please tick)New or recent onset EXERTIONAL chest pain suggestive of STABLE ANGINA within 3 months
Male ≥30 or Female ≥40yrs.
No known IHD or prior cardiac investigation within 5yrs
Please use scoring system below to ensure referral to appropriate CHEST PAIN service
Patient name: / Referring GP / Consultant / ward:
DOB: / Date of referral:
Hospital / NHS no: / GP name:
Address: / Practice address
Phone:
Interpreter needed YES / NO Language: / Phone: / Fax:
Chest pain details Score (calculate total)
Position on chest / Front of the chest / epigastric / neck / shoulders / jaw / arms / 1
Right-side / sub-mammary / very localised / 0
Type of pain / Constricting / cramping / heavy / dull ache / burning / 1
Stabbing / sharp / 0
Reproducible by manual pressure on chest wall / -1
Precipitating factor / Always on exertion, relieved by rest / 3
Both at rest and exertion / 1
Nothing in particular / unpredictable / 0
Breathing in / out / -1
Duration of episodes / 2-15 minutes / 1
Seconds to a couple of minutes / 0
More than 15 minutes to hours / 0
Total
If score is 3 / This may represent typical stable angina – REFER
If score is 2 / Possible atypical angina – if risk factors score 1 REFER, otherwise treat risk factors using primary prevention risk calculator
If score is 0-1 / It is unlikely to be stable angina – consider alternative cause for chest pain; if risk factors score 1, treat risk factors
Risk factors
Diabetes Mellitus / YES / NO / Family history of a 1st degree relative with CAD (60 years) / YES / NO
Cholesterol >6.47 mmol/L / YES / NO / Hypertension / YES / NO
History of smoking / YES / NO / Past history of IHD / YES / NO
Symptom onset weeks days
Clinical examination Murmur YES / NO Echo in past 5 years? ECG normal / LBBB / AF / other
Current medication
PLEASE FAX TO: 01962 825227
Additional information can be provided in a separate letter if necessary
CS Aug 2015