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Home: Work: Mobile No:Registered GP Name: Surgery address: Tel. no: Fax: e mail:Sex: Date of birth: Hospital number: Date of referral:Referred by: GP  FORMCHECKBOX  ED  FORMCHECKBOX  Other  FORMCHECKBOX Referring GP name (if different): Date & time of onset of symptoms: Date & time of first assessment by a clinician : ABCD 2 SCORE Only assign one score per area (eg symptoms > 60 mins scores 2)ScorePatient ScorePatient AdviceA = Age> 601Explain FAST assessment to patient He or she should not drive until he or she has been assessed at the hospital or clinic If there was a witness to the event, that person should accompany the patient to the hospital or clinic If the patient experiences any further event he or she should go immediately to A&EB = BP>140 Systolic and/or >90 Diastolic1C = Clinical FeaturesUnilateral weakness2Speech disturbance w/o weakness1D = Duration of Symptoms> 60 minutes210 59 minutes1D = DiabetesDiabetes1Total ABCD 2 Please add the Patient score and enter total herePatient has crescendo TIA (2 or more TIAs in last 7 days): Yes  FORMCHECKBOX  No  FORMCHECKBOX ABCD 2 = 1-3 - To be seen within 7 days, ABCD 2 = 4-7 or crescendo TIA - To be seen in next 24 hoursClinical FeaturesPresentRightLeftCurrent MedicationHemiparesis / arm weakness FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Give patient 300 mgm Aspirin stat then daily unless contraindicated and provided all symptoms have resolved. Ask patient to bring current medication / medication list to clinic. Hemiparesis /leg weakness FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Loss of sensation FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Loss of vision FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Double vision FORMCHECKBOX  FORMCHECKBOX  FORMCHECKBOX Dysphasia / loss of speech FORMCHECKBOX Blood Pressure /Loss of coordination FORMCHECKBOX Duration of symptoms to complete resolution: Past medical history / Vascular Risk FactorsHypertension FORMCHECKBOX Hyperlipidaemia FORMCHECKBOX Isch. Heart Disease FORMCHECKBOX Smoker FORMCHECKBOX Heart failure FORMCHECKBOX Obesity FORMCHECKBOX Peripheral vascular disease FORMCHECKBOX Previous stroke/TIA FORMCHECKBOX Atrial fibrillation FORMCHECKBOX Migraine FORMCHECKBOX Diabetes FORMCHECKBOX Is patient Aspirin Allergic / Aspirin intolerant Yes  FORMCHECKBOX  No  FORMCHECKBOX  History of Treatment / Other relevant information (please attach Patient Summary if available) Patient requires transport for appointment: Yes  FORMCHECKBOX  No FORMCHECKBOX Please refer to attached guidelines and referral information SHIP* Referral Proforma for Transient Ischaemic Attack (TIA) Referral / Admission Guidance & Contact Information  Contact Information: Basingstoke & North Hampshire NHS Foundation Trust: Fax No: 01256 313653 Phone No: 01256 313418 Bleep No: 2211 Frimley Park Hospital NHS Foundation Trust Fax No: 01276 604091 Phone No: 01276 604284 Bleep No: 720 Isle of Wight NHS Trust Fax and Phone No: 01983 552012 (all hours) Bleep No: 023 (out of hours) Lymington New Forest Hospital Fax No: 01590 663184 Phone No: 07766220908 for 'in hours' and 01590 663070 for 'out of hours' Portsmouth Hospitals NHS Trust Fax No: 02392 283686 Bleep No: 1788 Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust Fax No: 01202 705442 Phone No: 01202 705288 (for high risk patients whilst they are with you OR ask patient/carer to phone for appt ASAP (9am 4pm Mon Fri) Phone No: 01202 705387 (other stroke enquiries) Bleep No: N/A Salisbury NHS Foundation Trust Fax No: 01722 429146 Phone No: 01722 336262 ext 4760 (stroke nurse co-ordinator) Phone No: 01722 336262 ext 4141 (secretary) Bleep No (Stroke Medicine Registrar): 1490 Southampton University Hospitals NHS Trust Email:  HYPERLINK "mailto:UHS.TIA@nhs.net" UHS.TIA@nhs.net Phone No: 023 8120 5019 TIA Nurse mobile number: 07766800370 (Monday to Friday 8 4) SNP BLP 1592 Winchester & Eastleigh Healthcare NHS Trust Fax No: 01962 825570 Phone No: 01962 863535 Bleep No: 350 Phone No: 07799898673 or 07766254089 (to contact consultants)     SHIP* Referral Proforma for Transient Ischaemic Attack (TIA) Page  PAGE \* MERGEFORMAT 3 No No Yes Yes Has Patient had (TIA) event within the previous 5 days Patient presents with symptoms of TIA or minor stroke Refer IMMEDIATELY via attached form and by phone conversation if advice needed Higher Risk ABCD2 Score between 4-7 or crescendo TIA (2 or more TIAs in last 7 days) Yes Patient to be notified of an appointment for assessment within 24 hours Referral to TIA clinic TODAY by faxing this referral form Perform: ECG and copy with referral Bloods: FBC, ESR, Lipids Glucose, U&E, LFT Start Aspirin unless CI Advise: Lifestyle management Advise not to drive Give FAST info leaflet Patient will receive an appointment within 7 days Further event whilst waiting for an appointment: Call 999 Co morbidities If patient has any of the following: TIA plus AF TIA plus on Warfarin Young Patients with likely TIA and neck pain (under 40) TIA plus have prosthetic valve No    +R   0 1 4 5 6 D E F M N yl`XI`ljhyQCJU^JhyQCJ^JjhyQCJU^Jh$^JaJmHnHu#h(Whl;^JaJmHnHsH uh(Whl;5^JaJh(Whl;^JaJmHnHuh^JaJmHnHuhl;^JaJmHnHuhvhl;5^JaJhA^JaJmH nH sH tH hl;^JaJmH nH sH tH $h(Whl;^JaJmH nH sH tH     %]q(($2&`#$/@&If]gd " (($2&`#$/@&Ifgd "  |b<$2&`#$/@&If]gdkd$$Ifl08* t 6`20*44 la  $ 1 z ucKuuu$2&`#$/@&If]gdyQ$2&`#$/Ifgd " $2&`#$/@&If]gd " qkd$$Iflk8** t 6`20*44 laN O ] ^ _ g h i w x y z  ̗̿~qaqTqBqa#h+4hl;CJ ^JmHnHsH uh1^JmHnHsH uhvhl;^JmHnHsH uhl;^JmHnHsH uh(Wh " 5^JaJh " ^JaJmHnHuhl;^JaJmHnHuh(Whl;5^JaJjh$CJU^Jh$^JaJmHnHuh(Whl;^JaJmHnHujh$CJU^Jh$CJ^Jjh$CJU^J gUUU$2&`#$/Ifgd " kdj$$IflF8*4  t 6`20*    44 la    7 8 X Y | } ~    n o  ! 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