If more than one episode of TIA within 7 days (crescendo TIA) then GP to refer patient to ED/ED refer to local HASU Team.
If any queries please contact the On Call Stroke Consultant via switchboard
Reference/Priority
Referral Date:
Referral Date 	

	Priority:
Urgent	

	NHS Number:
NHS Number 	

Patient Details
Title:
Title 	

	Forename(s):
Given Name 	

	Surname:
Surname	

Date of Birth:
Date of Birth 	

	Gender:
Gender 	

	Ethnicity:
Ethnic Origin 	

Contact Details
Address Line 1:
Home Address House Name/Flat Number 	

	Address Line 2
Home Address Number and Street 	

	Address Line 3:
Home Address Village 	

Town:
Home Address Town 	

	County:
Home Address County 	

	Postcode:
Home Address Postcode 	

Phone:
Patient Home Telephone 	

	Mobile:
Patient Mobile Telephone 	

	Text Message Consent:

	
Email:
Patient E-mail Address 	

Referrer/Practice Details
Referring Name:
Referring User 	

	Referrer Code:
Free Text Prompt 	

	Practice Code:
Organisation National Practice Code 	

Clinic Details
Specialty:
General Medicine	

	Clinic Type:
Transient Ischemic Attack	

	Named Clinician:
     	

Provider Department Details
AutoBook - York Hospital	

Preferences
Vulnerable Patient:

	Vulnerable Reason:
     	

	Confidential/Silent Referral:

	
Preferred Contact Time:
     	

	Interpreter Required:

	Preferred Language:
Main Language 	

Referral Details
Non-clinical information for the booking team:
     	

Provisional Diagnosis:
Referral Reason 	

Smoking Status:
Single Code Entry: Smoking Status    	

Referral Reason/Letter Text

This part must be completed to be accepted
DATE SEEN	     	

DATE OF SYMPTOM ONSET	     	

Description of Patient Syndrome
Insert last consultation
Consultations 	
Other relevant detail
     	

	
If symptoms for more than 24hrs or patient on an anticoagulant, consider admission	
	
Please confirm you have advised your patient NOT to drive for one month as per DVLA driving regulations		

		
As recommended by NICE please confirm you have prescribed aspirin, or that it is contra-indicated	Aspirin 300mg OD prescribed 
Aspirin has not been prescribed because      		

Generic Patient Clinical Details
Patient Name: Title Given Name Surname 
Date of Birth:  Date of Birth 
NHS Number: NHS Number 
Summary Problem List
Problems
Current Repeat Medication List
Medication 
Allergies & Sensitivities
Allergies
Most Recent BMI
BMI
Most Recent Blood Pressure
Blood Pressure
Smoking Status
Single Code Entry: Smoking Status
Alcohol Intake
 Single Code Entry: Alcohol consumption

Investigations
FBC
Hb: Single Code Entry: Haemoglobin estimation
Platelets: Single Code Entry: Platelet count
WCC: Single Code Entry: Total white cell count

LFTs
Bilirubin: Single Code Entry: Serum bilirubin level
ALT: Single Code Entry: Serum alanine aminotransferase level
ALP: Single Code Entry: Total alkaline phosphatase
Total Protein: Single Code Entry: Serum total protein
Albumin: Single Code Entry: Serum albumin

U+Es
CRP: Single Code Entry: Serum C reactive protein level
ESR:  Single Code Entry: Erythrocyte sedimentation rate
Total Cholesterol: Single Code Entry: Total cholesterol:HDL ratio...
HbA1c: Single Code Entry: Haemoglobin A1c level - IFCC standardised
TSH: Single Code Entry: Serum TSH level