BACPR Referral

Patient Name (required)

DOB (required)

Contact Number (required)

Name (required)

Profession (required)

Surgery/Dept (required)

Address (required)

Postcode (required)

CARDIAC HISTORY (required)

NO previous cardiac historySTEMINSTEMIUnstable anginaStable anginaCABG

Current Angina (required)

YN

Details of Arrhthmias (required)

Arrhthmias (required)

YN

Date of Onset (required)

ICD/Pacemker date fitted (required)

Details/Settings

MEDICATION (PLEASE TICK THOSE CURRENTLY TAKEN) (required)

AsprinClopidogrel/ PrasugrelLipid lowering StatinBeta-blockerIvabradineAlpha BlockerACE InhibitorAngiotensin II Receptor BlockerNitrateGTN Spray/tabletsFrequency of use of GTNCalcium Channel BlockerPotassium Channel ActivatorsDiureticWarfarinNOACAnti – arrhythmic Specify typeInsulin

Other Medication (required)

BACPR Referral

PATIENT DETAILS

REFERRERS DETAILS

HISTORY & MEDICATION

ANGINA/ARRHYTHMIA HISTORY