Patient Name: 		<<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
DOB:			<<Patient Demographics:DOB>>
Medicare Card No.:	<<Patient Demographics:Medicare Number>>
Phone:			<<Patient Demographics:Phone (Mobile)>>
Address:		<<Patient Demographics:Address Line 1>> <<Patient Demographics:City>> <<Patient Demographics:Postcode>>

Date: <<Miscellaneous:Date>> |

Services Requested
1. [<<Service:   Consultation and ECG>>] - Consultation and ECG
2. [<<Service:   ECG>>] - ECG
3. [<<Service:   Echocardiogram>>] - Echocardiogram
4. Exercise Stress Echocardiogram with Baseline Echocardiogram <<EXERCISE STRESS ECHO and BASELINE ECHO>>

[<<With consultation>>] - With consultation
[<<Angina>>] - Angina: Constricting discomfort OR exertional symptoms OR relieved by rest/GTN
[<<SOBOE>>] - SOBOE: Undue exertional dyspnoea - ?cause
[<<ECG changes>>] - ECG changes: Consistent with CAD or ischaemia, in a patient without known CAD - ?ischaemia
[<<Known CAD>>] - Known CAD: New or worsening symptoms in patients with known coronary artery disease
[<<Moderate disease>>] - Moderate disease: Indeterminate lesion on CTCA/angiogram
[<<Congenital disease>>] - Congenital disease: History of congenital heart surgery - ?ischaemia
[<<Pre-op>>] - Pre-op with poor exercise capacity and past medical history of IHD/CVA/CCF/DM on insulin/serum Cr >170
[<<PCI or CABG/Valve Surgery>>] - PCI or CABG/Valve Surgery: Assessment of valvular disease or ischaemic threshold
[<<Silent Ischaemia>>] - Silent Ischaemia: ?Silent ischaemia or ?Ischaemia in patient with impaired cognition or expressive language skills

5. Holter Monitoring (24 Hours) <<HOLTER MONITORING (24 HOUR)>>

[<<Palpitations>>] - Palpitations (more than once a week)
[<<Dizziness, pre-syncope or syncope>>] - Dizziness, pre-syncope or syncope
[<<Asymptomatic arrhythmia>>] - Asymptomatic arrhythmia suspected (more than once a week) APPROPRIATE
[<<Surveillance>>] - Surveillance following cardiac surgical procedures that have an established risk of causing dysrhythmia

6. [<<Pacemaker Check / Consultation>>] - Pacemaker Check / Consultation
7. [<<24 Hour Blood Pressure Monitoring>>] - 24 Hour Blood Pressure Monitoring

Clinical Notes
<<Doctor:Name>> | Date: <<Miscellaneous:Date>>
Signature: | <<Practice/Location:Name>>
Provider No.: <<Doctor:Provider Number>> | Copy to:
157 Scoresby Road, Boronia 3155     Tel: 1300 122 888     Fax: 03 8080 0766     Email: contact@hom.com.au

PATIENT INSTRUCTIONS

• Please notify us if you are unable to attend.
•	Please wear a comfortable two piece attire and walking shoes for stress test.
•	Please bring your referral or doctor's letter to the appointment. Failure to do so may result in your appointment being cancelled. Bring your Medicare Card with you to the appointment.
•	Please stop these medicines 48 hours before the stress test, after consulting with your doctor: Atenolol, Sotalol, Metoprolol, Nebivolol, Bisoprolol, Carvedilol, Cardizem, Verapamil, Digoxin.

For more information please visit the website: http://www.hom.com.au

Phone: | 1300 122 888 | Email: | contact@hom.com.au
Fax | 03 8080 0766 | Website: | hom.com.au

LOCATIONS | Consult | HF Clinic | Echo | Stress Echo | ECG | ABPM | Holter | PPM Clinic | Urgent Cons.

BORONIA
(Main Rooms) 157 Scoresby Road, Boronia 3155

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BACCHUS MARSH
91 Gisborne Road, Bacchus Marsh 3340

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FAWKNER
1348 Sydney Road, Fawkner 3060

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GLEN WAVERLEY
Victorian Rehab Centre, 499 Springvale Road, Glen Waverley 3150

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MANNINGHAM
Specialist Centre, Level 5, 200 High Street,Teplestowe Lower 3107

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WHEELERS HILL SP024 Brandon Park Centre Wheelers Hill 3150 | • | • | | | | • | • | | •
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