Pain Management Clinic Referral Townsville Health Service District0

					Dr Matthew Bryant
Dr Farzana Mitra
Dr Martin McNamara
Dr Laurence Marshman



Pain Management Clinic
Doctor to complete this section only please

                                                                  Level 2 Medi-link Retail Centre
                                                                             Townsville Hospital
                                                                          100 Angus Smith Drive
                                                                           DOUGLAS QLD 4814
Client Referral Form –
                                                                                  Tel: 4796 2218
                                                                                  Fax: 4796 2223

Service delivery will include these steps:
       1. Patient referred to Pain Management Clinic Education Sessions
       2. On completion of classes, clients will be further assessed in relation to follow-on
           allied health management and a letter sent to referring practitioner outlining care
           plan.

Main Reason for referring this patient and principal issues to be addressed

……………………………………………………………………………………………………..

……………………………………………………………………………………………………..

Patient Diagnosis:………………………………………………………………………………...

……………………………………………………………………………………………………..

……………………………………………………………………………………………………..

Please enclose copies of any relevant letters, reports, and other documents.

DOCTOR DETAILS

Name………………………………………………Provider No………………………..

Practice address………………………………………………………………………….

Contact number(s)……………………………………………………………………….

I verify this client’s medical condition is stable with no crisis or emergency evident.
I undertake to participate in this patient’s continuing care, in collaboration with the THPMC.
Signed ………………………………………… Dated……………………………..

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS REFERRAL
Townsville Pain Management Clinic Referral Form


PATIENT TO COMPLETE SECTIONS A – C
A:    CLIENT DETAILS                                              DATE: ____/_____/____

MR / MRS / MISS / MS / DR / PROF SURNAME: _________________________________________________

GIVEN NAMES: __________________________________________PREFERRED NAME: ________________

HOME ADDRESS: ___________________________________________________________________________

                 ______________________________________POSTCODE_______________________


POSTAL ADDRESS: ________________________________________________________________________

                  _______________________________________________________POSTCODE_________

CONTACT NOS: HOME: ____________________________MOBILE:_________________________________

                 WORK: ____________________________ e-MAIL: _________________________________


DATE OF BIRTH: _____/_____/______       LANGUAGE(S) SPOKEN AT HOME: ___________________


NEXT OF KIN: NAME: _______________________________________________________________________

RELATIONSHIP TO YOU: ________________________________ CONTACT NUMBER: _______________


NAME OF YOUR FAMILY DOCTOR:___________________________________________________________

ADDRESS: __________________________________________________________________________________

____________________________________________________________________________________________


CONSULTING SPECIALIST NAME: ____________________________________________________________


MARITAL STATUS:         ( ) MARRIED             ( ) SINGLE NEVER MARRIED
                        ( ) DE FACTO            ( ) DIVORCED
                        ( ) WIDOWED             ( ) SEPARATED

                        SPOUSE / PARTNER’S NAME: ___________________________________

DO YOU HAVE ANY CHILDREN, OR DEPENDENTS?                  YES / NO


YOUR OCCUPATION:        CURRENT? _________________________________________________________

                        PREVIOUS? _________________________________________________________
PRESENT WORK STATUS:           ( ) FULL TIME           ( ) PART TIME
                               ( ) VOLUNTARY           ( ) STUDENT
                               ( ) RETIRED             ( ) RETRENCHED
                               ( ) UNEMPLOYED          ( ) HOME DUTIES / FAMILY

ARE YOU RECEIVING ASSISTANCE WITH DAILY ACTIVITIES? Please tick all that apply

        (   ) COMMUNITY NURSING                 (   ) GARDENING
        (   ) TRANSPORT                         (   ) MEALS
        (   ) HOME MAINTENANCE                  (   ) CLEANING
        (   ) SHOWERING / BATHING               (   ) OTHER ________________________
B:   INFORMATION REGARDING YOUR PAIN
WHICH PAIN AFFECTS YOU MOST?

       _________________________________________________________________________________

       _________________________________________________________________________________



WHEN DID IT START? ___________________________________ (PLEASE TRY TO BE PRECISE)
PLACE AN X WHERE YOUR PAIN IS, AND SHADE ANY REGIONS WHICH YOUR PAIN SPREADS INTO.
NUMBER ANY OTHER PAINS (2,3,4, ETC)




     WHICH OF THE FOLLOWING PEOPLE HAVE YOU SEEN ABOUT YOUR PAIN?
      (Tick all that apply)

       (   ) ACUPUNCTURIST                       ( ) ANAESTHETIST
       (   ) CHIROPRACTOR                        ( ) GENERAL PRACTITIONER
       (   ) HYPNOTHERAPIST                      ( ) GENERAL SURGEON
       (   ) HOMEOPATH / NATUROPATH              ( ) NEUROLOGIST
       (   ) MASSAGE THERAPIST                   ( ) NEUROSURGEON
       (   ) PHYSIOTHERAPIST                     ( ) ORTHOPAEDIC SURGEON
       (   ) PSYCHOLOGIST                        ( ) PSYCHIATRIST
       (   ) OCCUPATIONAL THERAPIST              ( ) SPECIALIST PHYSICIAN
       (   ) OTHER ________________________________________________

      OF THESE, WHICH HAVE BEEN MOST HELPFUL? _______________________________________

  LIST ANY OPERATIONS, PROCEDURES, INVESTIGATIONS YOU HAVE HAD IN THE PAST


OPERATION / PROCEDURE                YEAR           INVESTIGATION                     YEAR
                                                    (X-RAYS / SCANS / BLOOD / ETC)
    CURRENT MEDICATIONS AND DOSES

1                                              9

2                                              10

3                                              11

4                                              12

5                                              13
6                                              14
7                                              15
8                                              16


       PAST MEDICATIONS YOU HAVE TRIED UNSUCCESSFULLY

MEDICATION                          REASON STOPPED




    PLEASE DESCRIBE ANY ALLERGIES OR ADVERSE REACTIONS

ITEM                                REACTION




    VITAMIN SUPPLEMENTS AND HERBAL REMEDIES YOU TAKE
NAME                                REASON TAKEN
DOES PAIN AFFECT YOUR ABILITY TO DO ANY OF THE FOLLOWING TASKS?

      HOUSEWORK                (   ) yes         (   ) no         (   ) undecided
      SHOPPING                 (   ) yes         (   ) no         (   ) undecided
      CHILD CARE               (   ) yes         (   ) no         (   ) undecided     (N/A)
      LEISURE / HOBBIES        (   ) yes         (   ) no         (   ) undecided
      EXERCISE                 (   ) yes         (   ) no         (   ) undecided
      SLEEP                    (   ) yes         (   ) no         (   ) undecided
      RELAX                    (   ) yes         (   ) no         (   ) undecided
      SHOWER / BATHE           (   ) yes         (   ) no         (   ) undecided

       DO YOU REALISTICALLY EXPECT YOUR PAIN WILL EVER IMPROVE?
                     ( ) unsure   ( ) yes        ( ) no

      IF YOUR PAIN CAN BE REDUCED, BUT NOT COMPLETELY RELIEVED,
      HOW MUCH OF A REDUCTION IN YOUR PAIN WOULD BE ACCEPTABLE TO YOU?

      (CIRCLE) 10%     20%     30%         40%   50%        60%   70%        80%    90%

       DO YOU THINK YOUR PAIN IS CAUSED BY A DISEASE OR DIAGNOSIS THAT YOUR DOCTORS HAVE
       NOT FOUND, OR HAVE NOT TOLD YOU ABOUT?
                     ( ) unsure     ( ) yes       ( ) no

       PLEASE PROVIDE ANY OTHER IMPORTANT INFORMATION IN THE SPACE BELOW

       ____________________________________________________________________________________


       ____________________________________________________________________________________



PATIENT/CLIENT DECLARATION

I………………………………………………have provided complete, true and accurate
information. I accept that the Pain Management Clinic does not provide medicolegal
reports. I also understand that:

    The Education Day is an essential part of the Pain Management Pathway
    I will have a session with the Psychologist and Occupational Therapist before I will be
     seen by the Doctor. I may then be offered up to 6 sessions with the Psychologist and/or
     the Occupational Therapist
    It is my responsibility to ask for a repeat prescription at least one month before
     prescription required
    I am required to inform the Clinic if I am unable to attend appointments, if I fail to do
     this on 2 different occasions I will automatically be discharged from the clinic
    I understand that continuing scripts for opioids will not be prescribed at this clinic
    Drug screening may be required in some circumstances


Patients Signature………………………………………Date………………………

				
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Description: Pain Management Clinic Referral Townsville Health Service District0