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  2. 2012
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  5. Hotline Questionnaire
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What date/time were you paged?
MonthDayYear
  
 
 
 
What was the source of the call?
 
 
 
Patient Initials:
   
 
 
 
What is the Killip Class for this patient?
 
 
 
Did you accept the patient for transfer to HIU?
 
Yes
 
No
 
 
 
Is fibronolysis contraindicated for this patient?
 
No
 
Yes, specify:
 
 
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