Hhft Anticoagulation Therapy Referral & Counselling Form

HHFT ANTICOAGULATION THERAPY REFERRAL & COUNSELLING FORM

Anticoagulant Team Mon-Fri: 9am-5pm Direct Tel: 01256 313415 / 07876 508503

Email: Patient Tel: 01256 313295 / 01962 825624

Fax: 01256 314889 / 01962 825941

Patient details: (please complete)

Patient Name: / Hospital Number:
Referring clinician: / Home tel:
Work tel:
Mobile no:

Please indicate which service(s) you require: (please tick)

Warfarin counselling & dose management (nurse) with shared care follow-up
NOAC counselling (nurse) with follow up in primary care
Advice/support with anticoagulant initiation & management (consultant)
Please specify:

Indication for anticoagulation

The above patient requires anticoagulation with Warfarin or NOAC for the treatment of:(please indicate)

DVT * / AF *
DCCV? * / Prosthetic heart valve *
PE * / TIA / CVA * / Other (please state) *
Recurrent VTE * / Arterial disease *

If AF please complete CHADS2VASc score Known risk factors for clotting/ bleeding

(if less than 1 anti-coagulation is not recommended)

CHADS2VASc risk category / Points / Bleeding Risks / Clotting Risks
Congestive heart failure / 1 / Liver disease/alcoholism / Previous DVT/PE
Hypertension / 1 / Peptic Ulcer / Major surgery within last 12/52
Age 65-74 / 1 / Recurrent Falls / Paralysis or immobility
Diabetes Mellitus / 1 / Bleeding history (personal or family) / Family history of VTE or proven thrombophilia
Stroke / TIA/ thromboembolic / 2 / Reduced ability to safely self medicate / Active malignancy/Chemotherapy
Vascular disease (MI, PAD) / 1 / If on Aspirin/ Anti-platelet agent should it be stopped? If no state why? / Hospital admission within last 12 weeks, if so why?
Age ≥ 75 / 2
Sex if female / 1
Total

Any other significant information? (e.g. recent diagnosis cancer, pt has a compliance aid, needlephobia, allergies etc)

Please tell us what (if any) anticoagulation you have already prescribed including dates and dosage:

Please note that standard (normal) care for patients with acute VTE & active cancer is LMWH

Date / Drug / Dose / INR (if applicable)