ZJ GCA Luton Online Forms Current User: Not Logged In
Bedfordshire Hospitals
NHS Foundation Trust
Luton & Dunstable GCA New Patient Proforma (GCA1)
NHS Number:
Date seen in clinic
//
Date of Birth
//
Ethnicity:
Gender
Male
Female
Age
Referral routeGP / ACC / Medical / A+E / Ophthalmology / Luton Rheum / Other rheum
(free text for name of other rheum dept)
Fast Track Referal
Yes
No
Type of referral
New GCA suspect
Clinical GCA flare
Image or biopsy positive GCA flare
Date referred
//
Date referred to Luton Rheum dep
//
Date triaged
//

HISTORY:
History presenting complaint ( For each symptom duration ( in days ,weeks or months )
Headache: temporal / occipital / generalised / unilateral / bilateral (can be more than one of these)
Scalp Tenderness
Temporal tenderness
Jaw Pain
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