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Refer a patient

TIA fast track service referral

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Referrer details
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GP details
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Patient details
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Gender: * required


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Reason for referral
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If symptoms occurred more than 14 days previously please refer to Dr Mamun's neurovascular clinic.

Previous stroke/TIA?: * required


If more than one TIA in past 7 days admit to hospital.

ABCD score for TIA: * required





Duration of symptoms: * required



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If weakness or speech disturbance not present. Referral will not be appropriate.

Monocular visual disturbance?: * required


Risk factors: * required








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Infection control status
MRSA * required



   
Recent history of vomiting or diarrhoea * required


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e.g. scabies, shingles (if none please enter None in this field)

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