SCI Gateway Protocol Text
Mandatory fields are indicated by an asterisk
Diagnosis* Stroke /Cerebral TIA /Ocular TIA /Retinal Artery Occlusion /Other
Date of onset uncertain tick
Date of onset (dd/mm/yyyy)
Date of onset uncertain tick
Date of onset (dd/mm/yyyy)
Investigations (enter results if known)
- Haematology Not Done /Not Known /Result awaited /Result normal /Result abnormal
- Biochemistry Not Done /Not Known /Result awaited /Result normal /Result abnormal
- CXR Not Done /Not Known /Result awaited /Result normal /Result abnormal
- ECG Not Done /Not Known /Result awaited /Result normal /Result abnormal
(If abnormal, please specify in referral text tab)
Are there communication difficulties? please specify
Are there communication difficulties? please specify
Have you given Clopidogrel 300mg stat and continued 75mg? Yes/No
If suspected TIA, please answer the following:
- Age please specify
- BP: Systolic: please specify
- BP:Diastolic: please specify
Clinical Deficits:
Unilateral Weakness Yes/No
Speech Disturbance (No Weakness) Yes/No
Duration of Neurological Deficit >=60 Minutes / 10-59 Minutes / <10 minutes
Known DiabeticYes/NoPlease add any additional relevant information in Referral Text tab.
