BCPS Referral Form v1 0 FINAL by 5PifeCZ

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									                        Bath Centre For Pain Services
                        Referral Form (version 1.0)
Please complete the following form to enable us to apply for funding for a multidisciplinary
pain assessment. Send completed forms by e-mail (if using NHS secure addresses only) or
by fax or post. If you have any questions please ring 01225 473427.


Initial Checklist:
Ensure all the following questions can all be answered “Yes” before proceeding.

Has the patient had pain for   Yes                Have local services tried to    Yes
longer than 3 months?           No                meet the patient’s needs?       No
Is the pain having a           Yes                Has the patient been            Yes
significant impact on the                         assessed / treated within
patient’s life and              No                secondary care (e.g. a pain     No
functioning?                                      clinic)?

Contact Details:
Referrer            Name                                  Position
                    Address                               Phone




Patient             Name
                    DoB                                   NHS / CHI No
                    Address                               Phone




Patients GP         Name                                  Practice
(if not referrer)   Address                               Phone




Brief Pain History (cont’d over):

Pain related diagnosis / diagnoses

Pain location(s)

Approximate pain duration
Brief Pain History (cont’d):
Previous or ongoing
treatments, interventions
and surgeries (including
any relevant consultant
contacts and opinions)




Planned future
treatments, interventions
and surgeries

Other relevant medical
history




Impact of Pain:
Where relevant, outline impact of pain on:
Mood                                             Employment /
                                                 work /
                                                 education



Family and                                       Self care /
social                                           independence
relationships




Other relevant information:
Please highlight other relevant information (e.g. communication needs, concerns)




Referral completed by:

                                              Signature:
Name:
                                              (if sent by fax or post)


Position:                                     Date:


Please return the form using:
e-mail: pmu.enquiries@rnhrd.nhs.uk (only send e-mail from a secure NHS address)
fax: 01225 473461 (safe haven fax)
post: BCPS. RNHRD. Upper Borough Walls, Bath, BA1 1RL, UK.

								
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