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Stroke services - TIA referral

For urgent appointments, please call a stroke nurse on 01634 830000 bleep 883 and complete the form below:

TIA fast track service referral

Referrer details
* required
* required
* required
GP details
* required
* required
* required

Patient details
* required
* required
* required
* required
* required
   
Gender: * required


* required
* required
Reason for referral
* required
   

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



* required

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

Monocular visual disturbance?: * required


Risk factors: * required








* required
* required
* required
Infection control status
MRSA * required



   
Recent history of vomiting or diarrhoea * required


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

* required
* required
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