CARDIAC DIAGNOSTICS
Non-invasive Investigations

APPOINTMENT DETAILS
Date: ................................................................	Time: ....................................................	Location:   false Brighton    Moorabbin    Mulgrave    Warragul

PATIENT IDENTIFICATION
Name: .Patient Demographics.First Name Patient Demographics.Full Name	Date  of  Birth:Patient Demographics.DOB

Address: Patient Demographics.Full Address	Telephone  (H/M): Patient Demographics.Phone (Home)/Patient Demographics.Phone (Mobile)
	Medicare  No: Patient Demographics.Medicare Number
REFERRING DOCTOR INFORMATION
Name:Treating Doctor.Name	Signature: ...........................................................................................................................
Address: Treating Doctor.Address
Provider No: .Treating Doctor.Provider Number	Tel: Treating Doctor.Phone		Email: Treating Doctor.E-mail
CLINICAL NOTES AND REASON FOR TEST:

...................................................................................................................................................................................................................................................................................................................................................................................................

...................................................................................................................................................................................................................................................................................................................................................................................................
REQUEST  FOR	Date of request:Miscellaneous.Date.

false Transthoracic Echocardiogram (TTE)	Rural / Remote GP	 Valve Disease (55128) (MMM 3-7)
	 Adult (55126)	Specialist Referrals:	 Valve Disease (55127) 
	 Paediatric (<17 years in consultation with paediatric cardiologist)		 CCF / Structural Heart Disease (55129) 
	                     (55132)		 Adult Complex Congenital Heart Disease (55132) 
	Previous scan in last 24 months		 Paediatric (55132) (<17 years) in consultation with paediatric cardiologist
	 No (Medicare rebate available)
	 Yes (Medicare rebate restricted to specialist referral or rural GP)
	Date of last scan: ......................  Unknown

false Exercise Stress Echocardiogram with	Approved Indications:	 Typical or atypical angina	 Silent Ischaemia
	comprehensive baseline assessment (55141+55126)		 Known CAD - Ischaemia	 Abn ECG
false Exercise Stress Echocardiogram with		 SOBOE		 Pre-op: Risk
	limited baseline assessment (55141)		 Valve Haemobynamics
	Previous study within last 2 years
	 No (Medicare rebate available)                       Yes (Medicare rebate restricted to specialist referral)

false ECG Exercise Test	Age:       17 years or older (11729)         Younger than 17 years (11730)

false 12 Lead ECG (tracing and report) (11704)

   Holter Monitor (24 hours) (11716)	Indications:	*Episodes at least weekly?
		 (Pre) Syncope	 Yes (Holter or Event)
    Event Monitor (7 days) (11723)	  Palpitations*	 No (Event only)
	(>7 days) (11717)	 Suspected asymptomatic arrhythmia*
				 Other (describe in notes)

false Ambulatory BP Monitor (24 hours)

 Pacemaker Check    		Pacemaker Model: ............................................................................................................................................	 Unknown

                                          ACN 078 559 798
OUR TESTS:

c 12 LEAD ECG
A 12 lead ECG is a simple test that records the electrical activity of your heart and will take about 10 minutes to perform. Adhesive electrodes are placed on your chest, arms, and legs. You will need to remove your shirt/blouse for this test.
c ECHOCARDIOGRAM
This non-invasive test uses ultrasound waves to give us detailed images of your heart in motion, allowing us to assess your heart's structure and function.
Allow 40-50 minutes for this test.

c EXERCISE STRESS TEST
An Exercise Stress Test measures the performance of the heart, lungs, and blood vessels. In most cases, the test is carried out to assist in making a diagnosis of coronary artery disease. The test can also be
used to evaluate a patient's capacity to undertake certain physical activities and in the planning of an appropriate training program. This test usually takes 30 minutes. You will be required to walk as long as you can on a treadmill that increases in speed and slope every three (3) minutes. Wear comfortable clothing such as a tracksuit, shorts or slacks, and a pair of comfortable walking shoes.
c STRESS ECHOCARDIOGRAM
This test combines the Exercise Stress Test with echo images of the heart to make the test more informative and accurate. You should allow 30-40 minutes for the test, avoid a heavy meal beforehand, and wear comfortable walking shoes.
c HOLTER MONITOR
A Holter Monitor is a 24 hour recording of your heart rate and rhythm. This monitor usually takes 10 minutes to apply and 5 minutes to remove the next day. Five wires are connected to adhesive electrodes on your chest, and connected to a small recorder which you will carry for 24 hours. You will need to remove your shirt/blouse for this test and it is recommended that you wear a loose fitting top.
You will be given a diary to record any symptoms you may have, and you will not be able to shower until  the completion of the test.
c BLOOD PRESSURE MONITOR
A Blood Pressure Monitor records your blood pressure at regular intervals over 24 hours. This monitor usually takes 10 minutes to apply and 5 minutes to remove the next day. A blood pressure cuff is placed on your arm and connected to a small monitor that you carry with you on a shoulder strap or on your belt.
c PACEMAKER CHECK
A 15 minute procedure that wirelessly checks the pacemaker function.	
Melbourne Heart Care
Brighton
Head Office
Suite 16, 3 Male Street
Brighton VIC 3186
Tel: 03 9592 2177
Fax: 03 9592 3177	

	
	
Melbourne Heart Care
Moorabbin
Consulting Suite C, Ground Floor
Holmesglen Private Hospital
490 South Road
Moorabbin VIC 3189
Tel: 03 9592 2177
Fax: 03 9592 3177	

	
	
Melbourne Heart Care
Mulgrave
Suite 14, 529 Police Road
Mulgrave VIC 3170
Tel: 03 9795 0032
Fax: 03 9790 0644	

	
	
Melbourne Heart Care
Warragul
2/71 Victoria Street
Warragul VIC 3820
Off-street parking via Trumpy Ln
Tel: 035622 3244
Fax: 03 5622 3277	

	
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Melbourne Heart Care
Other pacing clinic locations:
     Rowville - 03 9780 8900
     Morwell - 03 5132 1289
     Wonthaggi - 03 5671 3353
     Berwick - 03 9592 2177	

www.melbourneheartcare.com.au
Your doctor has recommended that you use Melbourne Heart Care.
You may choose another provider but please discuss this with your doctor ﬁrst.