Clinic name:

Address:

County:

Postcode:

Telephone:

Fax:

Email:

Website:

Number of FH patients currently registered:

Number of FH patients forecast:

Over how many years:

Database software used:

Name of health authority:

Do you accept referrals?

yes      no

Special lipid service?

yes      no

Disorders treated:

Number of patients with probable FH:

Number of patients with definite FH:

Number of patients attending routine/follow up appointments:

Number of clinics per week:

Session length:

Numbers of patients seen per clinic:

Number of new patients per clinic:

New patient time per session:

Existing patient time per session:

Name of head of clinic:

Percentage of time spent each week in the clinic:

Number of consultants in clinic:

First consultants name:

First consultants percent week time in clinic:

First consultants email:

Second consultants name:

Second consultants percent week time in clinic:

Second consultants email:

Third consultants name:

Third consultants percent week time in clinic:

Third consultants email:

Number of other doctors in clinic:

First doctors name or job title:

First doctor percent week time in clinic:

First doctors email:

Second doctors name:

Second doctors percent week time in clinic:

Second doctors email:

Third doctors name:

Third doctors percent week time in clinic:

Third doctors email:

Number of nurses or other health professionals (hp) in clinic:

First nurse or other hp name:

First nurse or hp percent week time in clinic:

First nurse or hp email:

Second nurse or hp name:

Second nurse or hp percent week time in clinic:

Second nurse or hp email:

Third nurse or hp name:

Third nurse or hp percent week time in clinic:

Third nurse or hp email:

Are children seen in clinic?

yes      no

What age range are children seen:

Ages of children expressed as percentages (eg: 20% 16yr, 10% 15yr 30% 14yr etc):

Number of patients under age 16:

Is H·E·A·R·T UK digest received:

yes      no