ࡱ> 352 bjbjss S W111EEE8}D|ER!.==SSiWq }  ""%h 1K5"WKK Si !)))Kj8S1i )K )))iz GE) "!0R!)%74%)%1)vT)OD kR!KKKK% : NEUROPHYSIOLOGY Consultant Neurophysiologist Worcestershire Royal Hospital Dr Alison Blake MB(Hons) FRCP Charles Hastings Way Worcester WR5 1DD NEUROPHYSIOLOGY REQUEST Physiologist Tel: 01905 760697 Appointments Tel: 01905 733532 Patients Name/Address or Label PostcodeDoB TitleM/FI/P wardOP/Clinic Date/Pathway ID Hospital/NHS number: Dept/Hospital Patients Contact Details Home Telephone Mobile TelephoneWould patient accept appointment via email YES/NO Patients Email addressReferring Consultant/GP Name Hospital/Surgery name Date referredLocation report is to be sent to:Investigations Required (Please Circle) EEG Sleep EEG Ambulatory NCS EMG MSLT VEP Other (specify).Infection risk (Give Explanation) Results of other investigations History and relevant features of examination including symptoms. (Please give as much relevant information as possible or referral will be returned). (NB priority will be given on the basis of history and examination written on this form) What precise question do you want answered? Does the patient have a Pacemaker YES/NOIs the patient Anti-coagulated? YES/NOIs Patient on any medication? (Please State) GUIDELINES FOR COMPLETING THIS FORM: (PTO) GUIDELINES FOR COMPLETING THIS FORM: ALL sections must be completed. ALL MEDICATION must be listed. EEG A clear, concise history is needed. EEGs should not be used to diagnose epilepsy but to support the diagnosis. NERVE CONDUCTION STUDIES: These investigations are performed in a variety of clinic types. Based on the content of this request the correct clinic can be allocated. Inaccurate or incomplete forms lead to delays. A clear, concise history is needed together with your differential diagnosis. How long has the patient had symptoms? Distribution of symptoms? Is the patient diabetic? NB patients taking WARFARIN can have NERVE CONDUCTION STUDIES but if EMG is required their INR should be 1.5 or less within 48 hours of the appointment. We MUST know if the patient has a pacemaker or implanted defibrillator. 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