Section 1 | Patient Details

Name
DD slash MM slash YYYY
Address

Section 2 | Referring Consultant's Details

Referring Consultant Name

Test Service Request

E.g. Interpreter or learning difficulties?
Does the patient have an infection, or do they pose an infection risk to others?

Section 3 | Test Requested

Tick which tests you require
Please tick here if the test an INPATIENT - Please indicate which ward/ITU:

Section 4 | Please Complete for all Nerve Conduction Screening or EMG requests

Is the Patient a child?
Does the patient have a cardiac pacemaker/implantable defibrillator?
Is the patient on Warfarin or any anti-coagulation medication?
Is the patient on Warfarin or any anti-coagulation medication?
Does the patient have classic ‘barn-door’ CTS symptoms, without any ulnar nerve involvement?
Has the patient had CT decompression within last 6 months?
Does the patient have inconclusive MRI scan result for radiculopathy with possible motor weakness?
Does the patient have peripheral neuropathy with known diabetes or vitamin B12 deficiency?
Does the patient have Meralgia Paresthetica?