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Live Active Online Referral Form B

For patients WITH established heart disease.

To be completed by referring health professional. Please ensure patient meets referral criteria and the form is fully completed, otherwise they will not be accepted into the service.

This form allows access to technician led exercise testing to determine the safety of exercise prescription for the patient. The hospital will assume clinical responsibility for any recommendations to exercise.

Please note – these forms will only work when using a modern browser (e.g. Google Chrome, Microsoft Edge or Mozilla Firefox) and will NOT work when using Internet Explorer.

Only refer if yes
If NYHA is Grade 1 or 2 (i.e. none or only slight limitation of physical activity. DO NOT REFER if symptoms with mild activity or at rest)
BPM - DO NOT REFER if ventricular rate>80. See AF guideline re HR control
Please describe
(and No change in frequency or severity of angina) If "Yes" no further ETT required.Previous results will be used. If new diagnosis of angina please consider cardiac referral. OTHERWISE IF CHD - ETT REQUIRED.
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