NBT CARDIOLOGY MONITORING REQUEST FROM
FORM MUST BE ATTACHED TO CARDIOLOGY MONITORING RAS IN eRS	
PATIENT DETAILS:	
Name:	Full Name 	Date of Birth:	Date of Birth 	DD/MM/YYYY	
Patient NHS no:		Patient Address:		
GP DETAILS:	
Requesting GP:	Free Text Prompt 	Email Address:	Organisation E-mail Address 	
Organisation Name	Organisation Name 	Tel:	Organisation Telephone Number 	
Organisation Address:	Organisation Full Address (stacked) 			
PLEASE NOTE: ANALYSIS REPORTS WILL BE SENT TO GP POSTAL AND/OR EMAIL ADDRESS	

REASON FOR REQUEST (choose either Cardiac Monitoring or Ambulatory BP Monitoring)	

CARDIAC MONITORING REQUEST	
Symptoms	 Syncope		 Dizziness	
	Palpitations?	 PAF		 SVT		Ectopics	
	Other (please specify below)
     
	
Frequency of symptoms	 Daily	 Weekly	 Monthly	
Duration of symptoms	 Seconds	 Minutes 	 Hours	
Is the resting ECG Normal 	 Yes		 No (If no, please report abnormalities below)	
	     	
Device required:	 24-hour monitor	 Extended Monitor	

AMBULATORY BLOOD PRESSURE MONITIRING REQUEST	
Reason for test or indication:	Diagnosis of hypertension		
	Efficiency of treatment?		
	Are symptoms due to low BP?	Yes 		No 	
Most recent BP:	Blood Pressure 	
Symptoms:	     	

FUTHER INFORMATION:	
Relevant Medicine:	Please see relevant medication at the end of the form.	
Relevant History: (If non symptomatic, please provide reason for monitoring request)	      	
Further comment: (Covering letter may be attached if needed)	     	

Please note: Requests for monitoring will result in a report being issued.
Patients will not see a consultant.

Consultations 
Problems 
Medication
Allergies 
Investigations