The Carrdiac Clinic Suite 1, LLevel 2, Dubbo
o Private Hopsital Moran D
Dve, Dubbo NSW 2830 Ph: 02 6841 8820 Fax: 02 6841 8828 RAPID ACCCESS CHEST PAIN CLINIC – REFERR
RAL FORM PATIENT NAME:......................................... ................................................................................... PATIENT ADDRESS: ...................................................................................................................... DATE O
OF BIRTH: ........................................ PATIENT TTELEPHONE: ............................................. GP DETAILS:................................................................................................................................. GP ADD
DRESS: .................................................................................................. ............................. GP TELEEPHONE: ............................................. REFERR
RAL DETAILSS (presentingg history / exxamination ffindings): .................................................................. .................................................................................... RISK PR
ROFILE FOR CORONARY DISEASE:
Hyperteension Diabbetes Family H
Hx of premaature CHD Smooker
Capable of perform
ming ETT Y
Y / N New on
nset exertional chest paain Worsening of known ccoronary disease Other............................................................................................................................................... OTHER PAST MEDICAL HX: CURREN
NT MEDICA
ATIONS: EXCLUSSION CRITER
RIA: Patientss younger than 25 years old (unle ss high risk), patients w
with end staage disease
es (e.g. end stage COPD, teerminal can
ncer) in whoom a diagno
osis of angin
na will not aaffect future
e manageement The RAP
PID ACCESS C
CHEST PAIN C
CLINIC aims tto see patien
nts who have
e recent onseet angina (orr exacerbation of known coronaryy disease) rappidly as thesse conditionss are associatted with sign
nificant mortalitty. The RACPC is NOT for patients witth rest pain w
who should b
be referred tto ED OTHER INVESTIGA
ATIONS FIND
DINGS: ECG, CX
XR, Bloods ‐‐‐ please enclose with rreferral Referrals can be su
ubmitted on
nline, email ed or faxed
d Your paatient will be seen with
hin 2 weeks of referral