1
Patient:
Age/DOB:
MRN:
Date of Consult:
Date of Initial Consult:
Did Patient receive TPA? Yes No
Date of Repeat CT Scan:
Date of Follow up Visit:
TELESTROKE
FOLLOW UP NOTE
FOLLOW HISTORY
PATIENT’S WEIGHT / DATE MEASURED:
RESULTS OF INVESTIGATIONS:
February 2013
NEUROLOGICAL EXAM (OTHER):
February 2013
2
Item Score
1 a. Level of Consciousness
1 b. LOC Questions
1 c. LOC Commands
2. Best Gaze
3. Visual
4. Facial Palsy
5 a. Motor Arm - Left
5 b. Motor Arm - Right
6 a. Motor Leg - Left
6 b. Motor Leg - Right
7. Limb Ataxia
8. Sensory
9. Language
10. Dysarthria
11. Extinction and Inattention
TOTAL
Follow up
Aspect Score
Caudate
Lentiform
Insula
IC
MCA 1
MCA 2
MCA 3
MCA 4
MCA 5
MCA 6
TOTAL
CT Scan: (sketch lesion(s))
Hemorrhage
HMCA sign
Swelling
Eacement
> 1/3 MCA
ACA Lesion
PCA Lesion
Brainstem
Cerebella
Patient: MRN:
NIH SCORE
February 2013
3
CONSULTANTS OPINION:
Time: Date: Signature:
Dr. Blaine Foell Fax: (705) 789-1922 Dr. Frank Silver Fax: (416) 603-5768
Dr. Brian Van Adel Fax: (905) 577-8036 Dr. Hyman Rabinovitch Fax: (613) 228-9365
Dr. Chidam Yegappan Fax: (905) 521-6144 Dr. Martin del Campo Fax: (416) 603-5366
Dr. David Gladstone Fax: (416) 480-5753 Dr. Rick Swartz Fax: (416) 480-5753
Dr. Demetrios Sahlas Fax: (905) 577-8036 Dr. Wes Oczkowski Fax: (905) 529-8008 
Patient: MRN:
4
HOSPITAL TELEPHONE FAX
Ajax-Pickering
Rouge Valley Ajax Pickering
ER (905) 683-2320 x 1127
ICU (905) 683-2320 x 2217
ER (905) 428-82770
Health Records (905) 428-5217
Barrie
Royal Victoria Regional Health Centre
ER (705) 728-9802 x 66072
ICU (705) 728-9802 x 47620
ER (705) 728-5922
ICU (705) 739-5655
Medical Records (705) 728-0982
Belleville
Belleville General Hospital
(Quinte Health Care Corporation)
ER (613) 969-7400 x 2434
ICU (613) 969-7400 x 2429
Health Records (613) 969-0750
Brantford
Brant Community Health Care System
ER (519) 751-5507
CCU (519) 751-5501
ER (519) 751-5570
CCU (519) 751-5537
Health Records (519) 770-0226
Cornwall
Cornwall Community Hospital
ER (613) 938-4240 x 4726
CCU (613) 938-4240 x 2260
ER (613) 938-4069
Health Records (613) 930-4505
Dryden
Dryden Regional Health Centre
ER (807) 223-8820
CCA (807) 223-8205
Health Records (807) 223-2370
Fort Frances
Laverendrye Hospital
ER (807) 274-3261 x 4702
ICU (807) 274– 3261 x 4690
Health Records (807) 274-4832
Goderich
Alexandra Marine & General
Hospital
ER (519) 524-4505
ICU (519) 524-8323 x 5273
ER (519) 524-6267
ICU (519) 524-6681
Health Records (519) 524-5579
Hawkesbury
Hawkesbury and District General
Hospital
ER (613) 632-1111 x 454
ICU (613) 632-1111 x 300
ER (613) 636-6171
Medical Records (613) 636-6182
Kenora
Lake of the Woods District Hospital
ER (807) 468-9861 x 2435 ER (807) 468-4316
Kitchener
Grand River Hospital Corporation
ER (519) 749-4242
ICU (519) 749-4300 ext 2631
ED (519) 749-4285
ICU (519) 749-4214
Health Records (519) 749- 4311
New Liskeard
Temiskaming Hospital
ER (705) 647-1088 x 2118
SCU (705) 647-1088 x 2414 OR 2353
Health Records (705) 647-5800
OR (705) 647-4154
Niagara
Niagara Health System
Greater Niagara General Site
ER (905) 378-4647 x 53456
ICU (905) 378-4647 x 53411
Health Records (905) 358-0829
North Bay
North Bay Regional Health
Centre
ER (705) 474-8600 x 2134
CCU (705) 474-8600 x 2224
HR (705) 474-8600 x 2017
Health Records (705) 495-7931
Oshawa
Lakeridge Health Oshawa
ER (905) 576-8711 x 4560
CCU (905) 576-8711 x 3353
Health Records (905) 721-4753
Pembroke
Pembroke Regional Hospital
ER Primary RN (613) 732-3675 x 6826
ER Nursing Station x 6023
Health Records (613) 732-6343
Peterborough
Peterborough Regional Health Centre
ER (705) 876-5022
Stroke Beds (705) 743-2121 x 5197
Health Records (705) 876-5146
Sault Ste. Marie
Sault Area Hospital
ER (705) 759-3434 x 5420
ICU (705) 759-3434 x 5500
ER (705) 759-3708
ICU (705) 759-3643
Health Records (705)759-3703
Scarborough
Rouge Valley Centenary
ER (416) 281-7270
ICU (416) 281-7444
Health Records (416) 284-3155
Sioux Lookout
Meno Ya Win Health Centre
ER (807) 737-6580
In Patient Unit (807) 737-3030 x 4518
ER (807) 737-5262
Health Records (807) 737-5267
Sudbury
Health Sciences North
ER (705) 675-4790
ICU (705) 523-7100 x 4722
Health Records (705) 670-3831
Timmins
Timmins and District Hospital
ER (705) 267-6340
ICU (705) 267-6339
ER (705) 360-6006
ICU (705) 360-6081
HOSPITAL TELEPHONE & FAX