Practice to complete:
Recorder No.  	 Cable No. 	Disc No.	

HOLTER  MONITOR  DIARY

Date Fitted:                _ _ _/_ _ _/_ _ _    Time:  _ _ _ _ _ _ _ _ _ _ _ _ _ _
 
Please Return:           _ _ _/_ _ _/_ _ _    Return time: _ _ _ _ _ __ _ _ __
TIME (am/pm)	EVENT or SYMPTOM	ACTIVITY	

			

			

			

			

		

Patient to complete:
 Bed time:	 	 Wake up time:		

THIS DIARY IS TO BE RETURNED, EVEN IF BLANK

Tas Holters

287 Charles Street
Launceston  Tas  7250
Phone:  03 6311 1404
Fax:      03 6334 4942

FROM:
TAS HOLTERS NORTH WEST & NORTH EAST CLINICS

Please perform a Holter Monitor test for the following patient:	
Name	<<Patient Demographics:Full Name>>	Gender	<<Patient Demographics:Sex>>	
Address	<<Patient Demographics:Address>>, <<Patient Demographics:City>>, <<Patient Demographics:State>>, <<Patient Demographics:Postcode>>	
DOB	<<Patient Demographics:DOB>>	URN		
Phone	<<Patient Demographics:Phone (Home)>>	Mobile	<<Patient Demographics:Phone (Mobile)>>	
Medicare	<<Patient Demographics:Medicare Number>> 	
Ref		Exp	<<Patient Demographics:Medicare Expiry Date>>	

  Clinical Indications:	
		
	  	  Palpitations	  	  Syncope	  	  Dyspnoea	
	
	   	  Assess Heart Rate	    	  Arrhythmia	  	  Atrial Fibrillation	
	
		  Other:	

 Referring Dr	 <<Doctor:Name>>	
 Phone	 <<Practice:Phone>>	Fax:	 <<Practice:Fax>>	
 Address	 <<Practice:Name>>
 <<Practice:Address>>	
 Signature	
	
 Provider No	<<Doctor:Provider Number>>	RefDate:	 <<Miscellaneous:Date>>	

Next Appointment:	

If leads become disconnected, please re-attach following the guideline below:

	
Important information for patients:

While you are wearing the monitor please record:

1.	Any symptoms and the time they occur (for example chest pain, shortness of breath, uneven heart beats, dizziness, or anything unusual).

2.	Major activities (physical work or exercise etc.). 

3.	The time of taking medication.

While you are wearing the Holter monitor, please:

1.	DO NOT shower or get the monitor wet.

2.	Press the event button if you experience any symptoms.

3.	Return the diary sheet, even if blank. 

4.	Contact your referring doctor in approximately 5 working days to obtain the results of this test.

If you experience any problems, please contact:
Tas Holters: 6311 1404

Locations:
	Latrobe Family Medical Practice
45b Gilbert St
Latrobe
Ph:  6426 1141
		SmartClinics Devonport
8 Wenvoe St
Devonport
Ph:  6422 6200		City Medical Practice 
1/10 Marine Tce
Burnie
Ph:  6431 6511	
	Burnie General Practice
35 – 37 Mount St
Burnie  
Ph:  6431 7708		Saunders Street Clinic
37 Jackson St
Wynyard
Ph: 6442 1700
		Smithton Medical Services
14 King Street
Smithton
Ph:  6452 2555	
	Scottsdale Doctors Surgery
2 Fosters Rd
Scottsdale
Ph:  6352 2522		Ochre Medical St Helens
11 Pendrigh Place
St Helens
Ph:  6376 1777			

Template developed by Primary Health Tasmania. Updated November 2018