Lambeth / Southwark TIA Referral Form / Date / Method of Referral:
Clinical Referral email:
St Thomas’ Hospital:
King’s College Hospital: / Date of referral __/__/____ GP  Other 
Patient details / Patient GP Details
Name: / Name:
Address: / Address:
Date of birth: __ / __ / ____
Tel Home: / Tel:
Mobile: / Fax:
Clinical features / Present / Right / Left / History of Treatment / Other Relevant Information
Hemiparesis /arm weakness /  /  / 
Hemiparesis / leg weakness /  /  / 
Loss of sensation /  / Blood Pressure
/
Loss of speech / 
Vertigo / 
Double vision / 
Loss of co-ordination / 
Date of symptoms:
Duration of symptoms to complete resolution:
Past medical history / Vascular risk factors / Current Medications
Hypertension /  / Hyperlipidaemia /  / *Give patient stat dose 300mg aspirin daily, unless contra indicated (e.g. on warfarin) and provided all symptoms have resolved
Isch. Heart Disease /  / Smokes / 
Heart failure /  / Obesity / 
Diabetes /  / Previous Stroke/ TIA / 
AF /  / Migrane / 
PVD /  / Other / 
True aspirin intolerance: Yes  No 
ABCD2 Score / Score / Patient Score / Patient Advice
A = Age / >60 / 1 / Tell the Patient:
-He or she should not drive until he or she has been assessed at 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&E
B = BP / >140 Systolic and/or 90 Diastolic / 1
C = Clinical Features / Unilateral Weakness / 2
Speech disturbance w/o weakness / 1
Other / 0
D = Duration of Symptoms / >60 minutes / 2
10 – 59 Minutes / 1
< 10 Minutes / 0
D = Diabetes / Diabetes / 1
Total ABCD2 Score
Referral Information
Guy’s and St Thomas’ NHS Foundation Trust
Send to St Thomas’ A&E if any of the below apply:
  • ABCD2 Score ≥4
  • ≥ 1 TIA in a week
  • On Warfarin or in AF (Atrial Fibrillation)
  • < 50 yrs, with prominent neck pain / headache
Refer to GSTT TIA Clinic via email if ABCD2<4 and TIA suspected (Monday P.M. & Thursday A.M.)
Team Secretary (appointments, chase referral) 0207 1882515
TIA Referral email:
Stroke Team via St Thomas’ Switchboard 0207 1887188 (bleep 1765) Prof Rudd, Dr Bhalla, Dr Birns. / King’s College Hospital NHS Foundation Trust
Send to King’s A&E if any of the below apply:
  • ABCD2 Score ≥4
  • ≥ 1 TIA in a week
  • On Warfarin or in AF (Atrial Fibrillation)
  • < 50 yrs, with prominent neck pain / headache
Refer to KCH TIA Clinic via email if ABCD2<4 and TIA suspected (clinics take place Mon-Fri)
TIA referral email
TIA Nurse: Stephanie Drysdale 02032998027(bleep 100)
Stroke Registrar via King’s Switchboard: 020 3299 9000
(bleep 920/898).
IF SYMPTOMS PERSIST THROUGH CLINICAL ASSESSMENT THEN BLUE LIGHT TO NEAREST A & E.

Author: S.DrysdaleReview Date: 01/09/17