BNSSG LIPID CLINIC REFERRAL PROFORMA
For further guidance on referral guidelines and criteria please see ‘Who to refer’ section on Remedy. 
Practice Information	
Name of Organisation:	Organisation Name 	Organisation Contact Number and Email Address:	Organisation Telephone Number 
Organisation E-mail Address 	
Referring Clinician:	Free Text Prompt  	Referral Decision Date:	Long date letter merged  	

Patient Details	
  NHS Number:	NHS Number  	Name:	Full Name  
Home Full Address (stacked)  	
D.O.B:	Date of Birth   	Age:	Age  	Address:

		
Gender:	Gender(full)  			
Ethnicity:	Ethnic Origin       			
Tel:	Patient Home Telephone  			
Other:	Patient Mobile Telephone 			
For further guidance on guidelines see Remedy

Which of the ‘who to refer’ criteria does this patient fit? 

1.	Clinical suspicion of Familial Hypercholesteraemia                                                Yes  No  

2.	Suspicion of Familial Hypercholesterolaemia as identified using DES criteria  Yes  No 
(see the desktop flow chart)
                                                                                
3.	Patient or relative with high Lp(a)                                                                              Yes  No  

4.	Intolerant of Multiple statins (consider rosuvastatin 5mg weekly and titrate this up to daily)                                                                                                                                  Yes  No  
NHS Accelerated Access Collaborative » Statin intolerance pathway (england.nhs.uk)
5.	Not at target despite max treatment/ recurrent event on max treatment - consider inclisiran. Follow Inclisiran clinical guidelines on BNSSG formulary page (under Lipid guidance): https://remedy.bnssg.icb.nhs.uk/formulary-adult/local-guidelines/2-cardiovascular-system-guidelines/                                                                             Yes  No  

6.	Hypertriglyceridaemia                                                                                                   Yes  No  
	
Clinical history
Please outline brief clinical details and include lipid results as relevant to the referral.

     	
Family history 
Please include the following details regarding family history if referring on the basis of criteria 1-3 above. Only 1st/2nd degree relatives are relevant for these purposes.

Coronary Heart Disease in relatives aged < 60years                                   Yes  No  Not Known 
 
Coronary Heart Disease in relatives aged < 45years                                   Yes  No  Not Known 

Relatives aged 18 and over with LDL-Cholesterol 
 >4.9mmol/mol (or total cholesterol >7.5mmol/L)                                     Yes  No  Not Known 
 
Relatives aged under 18 with  LDL-Cholesterol 
>4.0mmol/mol (or total cholesterol >6.7mmol/mol)                                 Yes  No  Not Known 	
Clinical signs (please ensure completed if referring based on criteria 1-3)

Tendon Xanthomata                                                                                         Yes  No  Not Known 

Corneal arcus present <45years                                                                     Yes  No  Not Known 	

Consultations 
Problems 
Allergies 
Medication 
Investigations 
Height 
Weight 
BMI 
Blood Pressure 
HbA1c 
Single Code Entry: TSH (thyroid stimulating hormone) level  
Single Code Entry: eGFR (estimated glomerular filtration rate) using creatinine Chronic Kidney Disease Epidemiology Collaboration equation per 1.73 square metres  
Single Code Entry: Serum alanine aminotransferase level  
Single Code Entry: Serum cholesterol level  
Single Code Entry: Serum triglycerides level  
Single Code Entry: Serum high density lipoprotein cholesterol level  
Single Code Entry: Serum low density lipoprotein cholesterol level  
Single Code Entry: Serum non high density lipoprotein cholesterol level