Address:



|Patient Details NHS no :…………...……….…. |GP Name |

|Name & Address: |Surgery address: |

|Post Code: | |

|Home Phone: |Tel. no: |

|Work Phone: |Fax: |

|Mobile No: |Email: |

|DOB: Gender: M / F | |

| |Contact Name: ………………………………. |

|Mandatory Information |Are Patient’s symptoms atypical? Please Tick Π |

|Without this information your referral will be rejected | |

|Symptom Onset |λ Gradual onset or spread of symptoms |

|Date __ / __ / ____ Time __ : __ am/pm |λ Seizure or loss of consciousness |

| |λ Transient Amnesia |

|First Assessment by GP: |λ Isolated Vertigo and no other Cranial nerve features |

|Date __ / __ / ____ Time __ : __ am/pm |If ‘Yes’ to any of these questions STOP. This is unlikely to be a TIA. Consider|

| |alternatives referral route e.g. refer to General Medicine, General Neurology |

| |Clinic |

| |History of TIA Event: Include details of focal neurology. |

|TIA Symptoms Please Tick Πwhere yes | |

|Face weakness | |

|Arm weakness | |

|Leg weakness | |

|Speech disturbance | |

|Visual disturbance | |

|Have symptoms/signs FULLY resolved | |

|Past Medical History: |Medications: |

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|Vascular risk factors: Please Tick Π where yes |Patient Advice Please Tick Πas completed/advised |

| |Advise Patient not to drive until seen at clinic |

|Hypertension |Aspirin 300mg stat and continue od until seen in clinic (if NOT taking an or |

|Atrial fibrillation |antiplatelet agent or anticoagulant) |

|Diabetes |Clopidogrel 300mg stat and 75mg od until seen in clinic (if aspirin intolerant)|

|Smoking |Any witness should accompany the patient to clinic |

|Ischaemic heart disease |Patient should attend Frimley Park ED in the event of further symptoms |

|Previous stroke |Notify FPH TIA clinic of any patient mobility needs |

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They are more likely to have had a TIA if they have the following symptoms

1. Unilateral face, arm or leg weakness

2. Speech disturbance

3. Transient visual loss

Email this form to: fhft.fphtiareferral@

NOTE: faxed referrals are no longer accepted

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