Epic_EAP
Referral Date Today M-D-Y
* Patient First Name* must provide value
Patient Middle Name
* Patient Last Name* must provide value
* Patient Gender* must provide value
Male Female
* Patient DOB* must provide value
M-D-Y
Warning: DOB can't be a future date. Please re-enter DOB * Parent/Guardian First Name* must provide value
Parent/Guardian Middle Name
* Parent/Guardian Last Name* must provide value
* Parent/Guardian phone (mobile preferred)* must provide value
Enter a 10 digit Phone Number
* Parent/Guardian phone Type* must provide value
Mobile Home Work
* Referring Provider NPI#* must provide value
* Referring Provider First Name* must provide value
* Referring Provider Last Name* must provide value
* Referring Provider Office Phone Number* must provide value
Enter a 10 digit Phone Number
* Referring Provider Street Address* must provide value
* Referring Provider City* must provide value
* Referring Provider State* must provide value
AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AS DC FM GU MH MP PW PR VI
* Referring Provider Zip* must provide value
Enter a 5 digit Zip Code
* Referring Provider Fax Number* must provide value
Enter a 10 digit Fax Number
* Visit needed ASAP (Clinically needs to be seen in 1 week)* must provide value
Yes No
* Reason for ConsultationCheck all that apply to the patient
* must provide value
Abnormal ECG
Abnormal Echocardiogram
Chest Pain
Genetic Disorder
Murmur
Palpitations
Prevention Clinic
Syncope
Second Opinion
Other
* Please provide additional detail* must provide value
Abnormal ECG: Why was the ECG ordered?
Abnormal ECG: What are you concerned with?
Abnormal ECG: Any other symptoms?
Abnormal Echo: Why was the Echo ordered?
Abnormal Echo: Any other symptoms?
Abnormal Echo: What are you concerned with?
Chest Pain: Associated with exercise? Yes
No
Chest Pain: And associated with syncope? Yes
No
Chest Pain: Any other symptoms? Yes
No
Chest Pain: Describe other symptoms you have.
* What genetic diagnosis / suspected diagnosis or concern does the patient have?Check all that apply to the patient
* must provide value
Genetic Syndrome associated with cardiac condition
Multiple Congenital Anomalies
Aortopathy / Aortic dilation / Aortic Aneurysm
Family history of Aortopathy
Family history of Cardiomyopathy
Ehlers Danlos Syndrome
Inherited Arrhythmia
Family history of Sudden Death
Rett Syndrome
Postural Orthostatic Tachycardia Syndrome
Familial Hyperlipidemia
Mucolipidoses / Glycogen storage disorders
Muscular Dystrophy
Other
* Please provide additional detail* must provide value
* What is the purpose of the referral?* must provide value
Consult
Transfer of Care
*What are the symptoms / diagnosis that need an evaluation by cardiology?Check all that apply to the patient
* must provide value
Not EDS / Not Applicable
Aortic Dilation / Aneurysm
Classic EDS / Cardiac Valvular EDS / type I-II EDS
COL3A1 mutation / Vascular EDS / type IV EDS
Dizziness
Mitral Valve Prolapse
Postural Orthostatic Tachycardia Syndrome (POTS)
Syncope
Murmur: Good femoral pulse? Yes
No
Murmur: Is the child tachypneic? Yes
No
Murmur: Is there cyanosis? Yes
No
Murmur: Any signs of CHF? Yes
No
Murmur: Any other symptoms? Yes
No
Murmur: Describe other symptoms you have.
Palpitations: How often do palpitations occur?
Palpitations: How long do they last?
Palpitations: Any documented heart rate? Yes
No
Palpitations: What is the documented heart rate?
Palpitations: Any associated with syncope? Yes
No
Palpitations: Any documented SVT? Yes
No
Palpitations: Documented SVT?
Syncope: Number of syncopal episodes
Syncope: Number of dizzy spells
Syncope: Any episodes associated with exercise? Yes
No
Syncope: Any other symptoms? Yes
No
Syncope: Describe other symptoms
* Second Opinion: Reason for Second Opinion* must provide value
Family History of Sudden Cardiac Death? Yes
No
Approximate age at time of death?
What is the relationship to patient? Parent
Grandparent
Sibling
Other
Other (Please describe)
Family History of Cardiomyopathy Yes
No
Type of Cardiomyopathy Primary Dilated
Primary LVNC
Primary Restrictive
Primary Hypertrophic
Secondary Ischemic
Other
Unknown
Other (Please describe)
What is the relationship to patient? Parent
Grandparent
Sibling
Other
Other (Please describe)
Family History of Long QT Syndrome? Yes
No
What is the relationship to patient? Parent
Grandparent
Sibling
Other
Other (please describe)
Prior Tests Performed?Check all that apply to the patient
ECG
Echocardiogram
CXR
Holter
Cardiac Catheterization
Cardiac MRI
Other
Other Tests Performed
Preferred Location(s), If known Medical Center
West Campus
The Woodlands
Cy-Fair
Sugar Land
Kingwood
Clear Lake
Austin
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