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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: email@example.com (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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