Bromley Stroke & TIA Service Referral Form 
This document contains merged data which appears in the red framed table at the bottom of the form. Please ensure that irrelevant data is removed.

Patient Details	
Title: Title 	First Name: Given Name 	Surname: Surname 	
NHS Number: NHS Number 	Date of Birth: Date of Birth 	Gender: Gender 	Age: Age 	
Address: Home Full Address (single line) 	
Telephone:        (Home) Patient Home Telephone          (Mobile) Patient Mobile Telephone 	
Referral Details	
Date of Referral:
Short date letter merged 	Form Completed By: Current User 
Referring GP (If form completed on GP's behalf): Free Text Prompt       	
Surgery: Organisation Name 	National Practice Code: Organisation National Practice Code 	
Address: Organisation Full Address (single line) 	Telephone: Organisation Telephone Number 	
Email: Organisation E-mail Address 	Fax: Organisation Fax Number 	

About this Form	
This form should be used for all referrals to Princess Royal University Hospital where stroke or transient ischaemic attack is suspected.
Unless given directly to ambulance staff, this form should be emailed to kch-tr.pruh-tia@nhs.net	
Please complete sections 1 to 5 for all patients	

1.	
1.	1. Special Requirements	
2.		 Patient is immobile		 Patient requires hoist
3.		 Patient Transport		 Translator (Language?)      	 Other      	
1.	
4.	2. Clinical History (You may alternatively attach relevant consultation notes at section 5.)	
5.	Description of symptoms	6.		
7.	Duration of symptoms (to complete resolution)	8.		
9.	When did episode(s) occur?	10.		
1.	
11.	3. Consider Alternative Diagnoses. 	
Isolated dizziness, isolated vertigo without cranial nerve signs, confusion without dysphasia, amnesia, bilateral sensation loss, seizures, loss of consciousness are UNLIKELY to be symptoms of stroke or TIA so you should consider alternative diagnoses and/or referral pathways.

  Please acknowledge that you have read this advice before proceeding.	

12.	4. Risk Stratification. (Please follow the flow chart below and complete the relevant checkboxes)	
Indicate symptoms present
  Loss of Power – arm, leg or face   Which side?  

Emergency!

Call emergency ambulance.
Give this form to the ambulance crew, or email it if patient is not present e.g. following a telephone consultation.

Symptoms are still present

Patient in AF or on an anticoagulant

 Loss or slurring of Speech 
 Loss of vision / Double Vision 
 Unilateral Loss of Sensation    Which side?  	
	
Yes 	

No 	
Yes 	

HIGH RISK – URGENT

Refer for urgent assessment today.

Weekdays 9am – 9pm
Bleep the Registrar
PRUH: 01689 863 000 Bleep 195

9pm – 9am & Weekends
Do not call (give this form to the patient or ambulance crew, to take to ED)

Advise the Patient 

They should not drive until assessed at the hospital or clinic.

If there was a witness to the event they should accompany them to the appointment.

If they experience any further events they should call 999.  

	
No 	
No 	

2 or more events in the last week

Yes 	
Yes 	

	
No 	
Calculate ABCD2 Score	Score	
A	Age	>60 years		
B	BP	>140 systolic and/or >90 Diastolic		
C	Clinical Features	Clinical Features		
D	Duration	Duration		
D	Diabetes			
Total ABCD2 Score		
No 	
Yes 	

LOW RISK
Prescribe 300mg aspirin stat and then once daily.
Email form to kch-tr.pruh-tia@nhs.net
 If concerned, consider discussing with stroke JCF on 01689 863 000, bleep 195 or with the stroke consultant on-call.

Advise the patient that:
They will be provided with an appointment by telephone usually within 3 working days.
They should not drive until assessed at the hospital or clinic.
If there was a witness to the event they should accompany them to the appointment.
If they experience any further events they should call 999.

ABCD2 Score = 4 or greater

1.	
13.	5. Additional Information ( Insert relevant consultation notes or referral letter here)	

Patient Summary

Problems 
Single Code Entry: O/E - blood pressure reading  
Medication 
Allergies 

End

Email: kch-tr.pruh-tia@nhs.net

Free Text Promptdespatching.]