Email this form to: [email protected]
Note - Faxed referrals no longer accepted.
Kingston hospital TIA clinic referral form
REFERAL INFORMATION
Paramedic ☐ Other ☐
Trust use only :
Date and time of first contact with health care professional :
Clinic Date :
Date :
Source of referral :
GP ☐
ED ☐
AAU ☐
Clinic time (24 hour clock) :
Time (24 hour clock) :
Name of referrer :
Referrer contact phone number:
PATIENT INFORMATION
SURNAME:
Date of Birth
Mr ☐ Miss ☐Mrs☐ Ms☐Other:
Gender :
Address:
FIRST NAME:
NHS Number:
Home Tel:
Mobile /Daytime Tel.
Carers Name:
Carers Telephone number:
Transport required : Y ☐N ☐
Type:
Handed? Left ☐ Right ☐
Preferred Language:
Interpreter required Y ☐N ☐
Brief History:
Previous TIA’s or Stroke Y ☐ N ☐
If yes:


When?
How many?
ABCD2 SCORE – IF PRESENTING WITHIN 7 DAYS
Points
A
Age
B
Blood pressure
C
Clinical features
D
Duration
Diabetes
> 60 years
60 years
Systolic > 140 or
diastolic > 90 mmHg
Unilateral weakness
Speech disturbance without weakness
Sensory Loss / other symptoms
≥ 60 minutes
10 – 59 minutes
<10 minutes
Present
Absent
TOTAL SCORE
1point
0 points
1 point
2 points
1 point
0 points
2 points
1 point
0 points
1 point
0 points
:
Email this form to: [email protected]
Note - Faxed referrals no longer accepted.
ABCD2 scores.
If :
 4 or more points - OR
 More than1 event in 1 week - OR
 Patient on anticoagulation
Follow high risk pathway
Past medical history:
Family History:
Social history:
Current Drug therapy:
Please start Aspirin 300mg immediately.
If Aspirin intolerant consider alternative anti-platelet.
Please specify if on Aspirin at the time of the event and /or other anti-platelet drug(s):
 On Warfarin?
 Why?
 Most recent INR result and date (if known):
Known risk factors
Previous TIA / CVA ☐
IHD ☐
☐
Impaired LV function
Hypertension
☐ Diabetes ☐
Peripheral Vascular disease ☐
Hyperlipidaemia
☐
Known Carotid disease
Obesity ☐
Alcohol
☐
Atrial Fibrillation ☐
☐
Smoking :
Current ☐
Ex
Number per day ?
☐
Clinic Information
Patients will be contacted by telephone after their referral is triaged, they will be given the most
appropriate appointment time and date according to their clinical priority.
Hours: every weekday
Location: Acute assessment Unit, Kingston Surgical Centre.
Map Location: H – Level 3 – Please click on web map (PDF)
Kingston Hospital
Galsworthy Road
Kingston Upon Thames
Surrey, KT2 7QB
Telephone: 0208 934 2321 , Elderly Care is option 4
kingston-web-map-6january-2016.pdf