The Congenital Cardiac Personal Health Passport
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1 The Congenital Cardiac ersonal Health assport This belongs to: It would be a good idea to wear an alert bracelet/necklace or carry a card at all times. Keep this assport available at all times.
2 atient passport This is your patient passport which is designed to hold important information about your heart condition and assist communication about your health and treatment. lease take it with you when you are seen as an Outpatient or require any medical advice or admission to a Hospital. Show the booklet to your Consultant, RMO, Nurse, or any other Healthcare rofessional involved in your care when you see them. You will also receive a communication card to carry with you at all times. Advice and Concerns please contact: Chris Hague, Adult Services Matron / Liza Reyes, Cardiac Sister at The Harley Street Clinic, 35 Weymouth Street, London, W1G 8BJ Tel: Fax: E Mail : ersonal Details: Name: Hospital Number: Address: Contact number: London Details: First Language: Emergency Contact Next of Kin Name: Next of Kin Contact number: Relationship: Date of Birth: Consultant: 2 The Congenital Cardiac ersonal Health assport The Congenital Cardiac ersonal Health assport 3
3 G:Consultant: Name: Allergies Or Sensitivities: ractice address: Contact Number: Medications you MUST NOT receive without Consultation with Cardiology Consultant Embassy: Name: Embassy Dr: Contact Details: Blood Group: Special Blood Requirements: Anticoagulation therapy: 4 The Congenital Cardiac ersonal Health assport The Congenital Cardiac ersonal Health assport 5
4 Your Heart Diagnosis: Diagram Update following rocedures: Diagram: Operations /Interventions: 6 The Congenital Cardiac ersonal Health assport The Congenital Cardiac ersonal Health assport 7
5 How this affects you (The Consultant or CNS will document what you need to consider) Exercise recommendations: Emotional Support referral : Expected Outcomes during lifetime discussed Topic Discussed Signed Endocarditic rophylaxis : Dental Review frequency: Dentist Name + Contact: Antibiotic Cover: acemaker/icd Therapy: Type: Settings: Information: Nutrition,Weight and BMI: regnancy and Contraception: 8 The Congenital Cardiac ersonal Health assport The Congenital Cardiac ersonal Health assport 9
6 Emotional Support referral : Expected Outcomes during lifetime discussed Medications: Topic Discussed Signed Date Dose When Medication and action summary 10 The Congenital Cardiac ersonal Health assport The Congenital Cardiac ersonal Health assport 11
7 Appointments Record: re Consultant Review Bloods,CXR,Echo and other tests will be arranged as requested by Consultants. Appointments Appointments Time Date lace and Reason for appointment Time Date lace and Reason for appointment 12 The Congenital Cardiac ersonal Health assport The Congenital Cardiac ersonal Health assport 13
8 Appointments Appointments Time Date lace and Reason for appointment Time Date lace and Reason for appointment 14 The Congenital Cardiac ersonal Health assport The Congenital Cardiac ersonal Health assport 15
9 This page is specifically for the nurses, Dr s and any other healthcare professional to write and document information. This page is specifically for the nurses, Dr s and any other healthcare professional to write and document information. Date & Time Signature & name Communication Date & Time Signature & name Communication 16 The Congenital Cardiac ersonal Health assport The Congenital Cardiac ersonal Health assport 17
10 This page is specifically for the nurses, Dr s and any other healthcare professional to write and document information. Life Style Guidelines and Contacts: Date & Time Signature & name Communication 18 The Congenital Cardiac ersonal Health assport The Congenital Cardiac ersonal Health assport 19
11 ADDINGTON ST. ANDFORD STREET TMAN UARE B A K E R S T R E E T CHILTERN STREET BAKER STREET M A R Y L E B O N E NOTTINGHAM LACE The Harley Street Clinic MOXON STREET LACE HIGH STREET MANDEVILLE MARYLEB W I G M O R E S T R E E T JAMES ST. ONE DEVONSHIRE LACE WEYMOUTH WIMOLE STREET H A R L E Y S T R E E T ARK CRESCENT L A C E R O A D DEVO N S H I R E S T O R T L AN D CAVENDISH L. REGENT S ARK STREET NEW CAVENDISH STREET WELBECK ST The Harley Street Clinic Molecular Imaging Centre CAVENDISH SQUARE REGENT STREET GREAT ORTLAND STREET G R E A T O R T L A N D E U MORTIMER ST S T R E E T CLEVELAN H O X F O R D BOND STREET S T R E E T OXFORD CIRCUS How to find us By car The nearest long stay National Car ark (NC) is in Cavendish Square. Short stay meter parking is also available in surrounding streets as well as on Harley Street. By train The nearest tube stations are Regent s ark (Bakerloo line), Baker Street (Bakerloo, Circle, Hammersmith and City, Jubilee and Metropolitan lines) and Bond Street (Central and Jubilee lines). By bus Bus routes 18, 27, 30, 205 and 453 all stop near the Molecular Imaging Centre. The Harley Street Clinic 35 Weymouth Street London W1G 8BJ
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