Author: Nurse Platinum Medical
Last saved by: Reception | Cardiac & Vascular Diagnostics

For all appointments & reports
		T: (07) 3350 2222     F:33502777
		E: reception@cavd.au
                811 Gympie Road, Chermside QLD 4032

EXAMINATION NEEDED:
Cardiac  Investigations
□    Echocardiography				□    Exercise Stress Echocardiogram**
□    Holter Monitor (24hr)			□    24 Ambulatory Blood Pressure Monitor
□    ECG (Reported)				□    Consultation with Cardiologist

** For diagnostic exercise testing, patients should discontinue beta blockers, digoxin, verapamil and diltiazem 48 hours prior to testing. 

PATIENT   DETAILS
Patient Name:  <<Patient Demographics:Full Name>>          Date of birth:  <<Patient Demographics:DOB>>
Postal Address:  <<Patient Demographics:Full Address>>
Phone number:  <<Patient Demographics:Phone (Home)>>/<<Patient Demographics:Phone (Mobile)>>
Medicare No. : <<Patient Demographics:Medicare Number>> Exp: <<Patient Demographics:Medicare Expiry Date>>

MEDICARE CRITERIA for TESTING:  
Please tick appropriate Symptoms
□  Shortness of breath    	□  Chest pain		□  Pre-syncope     
□  Syncope     			□  ECG Changes 	□  Pre-operative assessment
□  Recent hospital admission for cardiac reasons    

Please tick any Previous History:
□  Coronary artery disease    	□  Previous Stents   		□  Coronary artery bypass surgery 
□  Valvular Heart Disease 	□  Diabetes   			□  Hypertension   
□  High cholesterol 		□  Atrial fibrillation/flutter    	□  Supraventricular tachycardia (SVT)     
□  Pacemaker/Defibrillator 	□  Alcohol Yes  / No	

MEDICATION LIST:
<<Clinical Details:Medication List>>

ALLERGIES:
<<Clinical Details:Allergies/Adverse Reactions>>

SMOKING HISTORY:
<<Clinical Details:Smoking>>

FAMILY HISTORY:
<<Clinical Details:Family History>>

PAST HISTORY:
<<Clinical Details:History List>>

REASON FOR REFERRAL: 
PLEASE ATTACH A COPY OF RECENT BLOOD TESTS AND ANY PRIOR CARDIAC INVESTIGATIONS TO THIS REFERRAL

REFERRER DETAILS 
Referrer Name: 	<<Doctor:Name>>                  Signature: 

Provider Number:  <<Doctor:Provider Number>> 	Date: <<Miscellaneous:Date>>

** Please email/fax us a copy of this referral in order to get an appointment. 
https://cardiacandvasculardiagnostics.com.au/