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									                                                                                                                 NHS North West London

                                   PPwT form – Pain Management Programmes (PMP)


                         This form replaces all previous ones that relate to this procedure.
This form confirms that the patient meets the NW London PPwT criteria. A completed form submitted to the email
                                         address below supports funding.

                           The criteria are outlined at: www.westminster.nhs.uk/English/about-
                            us/northwestlondon/Pages/ifrservice_procedures_covered.aspx.

       To register this referral, email it to PPwTNW.London@nhs.net only using your nhs.net email account.
                  Also, send a copy of this form to the normal referral route that you have locally.
             If you wish to send an accompanying letter, please do so. All referrals must be e-mailed.

                                            DO NOT PUT THIS FORM IN THE POST

PATIENT                                                                     REFERRER
                 «PATIENT_Forename1»                                                                   «PATIENT_Registered_GP»
Name                                                                        Name
                 «PATIENT_Surname»
Address          «PATIENT_BlockAddress»                                     Address                    «PRACTICE_BlockAddress»
Telephone        «PATIENT_Main_Comm_No»                                     GP practice code
DOB              «PATIENT_Date_of_Birth»                                    Telephone                  «PRACTICE_Main_Comm_No»
NHS number       «PATIENT_Current_NHS_Number»                               Fax
Gender           «PATIENT_Sex»                                              E-mail
                                                                            Date of referral           «SYSTEM_Date»

LANGUAGE                                                                      NHS TRUST
Interpreter      YES          NO                                            Trust (preferred
required?                                                                   provider)
Language                                                                    Has the patient
                                                                            previously visited         YES           NO
Ethnicity                                                                   this hospital?

THRESHOLDS FOR TREATMENT

Inclusion criteria:

1) Clinical staff from the pain management programme has assessed the                                  YES           NO
patient and agreed that they would benefit from the programme

2) The patient has chronic non-malignant pain of least 3 months duration,
which is causing significant disability and/or distress, and a negative impact                         YES           NO
on quality of life.

3) The patient is able to communicate in the language in which the PMP is
conducted (a trained independent interpreter may facilitate successful                                 YES           NO
participation)

Exclusion criteria:

1) The patient has active psychological or psychiatric problems which require                          YES           NO
urgent attention, or which preclude the use of cognitive and behavioural
methods in a group (including severe cognitive impairment);

             Latest version of the form is available at www.westminster.nhs.uk/English/about-us/northwestlondon/Pages/ifrservice.aspx
                                                              Version 0.1 (20.3.2011)
                                                                                                                 NHS North West London

2) The patient has current primary drug or alcohol problems;                                           YES           NO

3) The patient has severe disability or significant medical condition such that
the basic requirements of attending treatment exceed the patient’s current                             YES           NO
capacity


Other supporting Information for referral - these are merge fields - please edit as required
Current Consultation:-
«CURRENT_CONSULTATION»

Past Medical History:
«MEDICAL_HISTORY»

Medication
«REPEATS»

Allergies – H/O allergies not recorded
«DRUG_ALLERGY»




END OF FORM




             Latest version of the form is available at www.westminster.nhs.uk/English/about-us/northwestlondon/Pages/ifrservice.aspx
                                                              Version 0.1 (20.3.2011)

								
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