REQUEST FOR PAIN MANAGEMENT APPOINTMENT 
ReferralNet: (BH Outpatients)
FAX: 03 4215 1383
							
GP Referral
		Referral Date: <TodaysDate>
Feedback Requested:  Yes	

Referral to:
Barwon Health Pain Management Unit 
(Director, Dr Louise Brennan)
Phone: 03 4215 1398 (GP Hotline)

Referral Urgency: <Referral Urgency>
Referral valid for: <Referral valid for>
Telephone advice required only?
<I only require telephone advice to help manage this patient>		Referring General Practitioner:
Name:<DrName> 
Practice: <Practice> 
Address:<UsrAddress>
Phone: <UsrPhone>   
Fax:  <UsrFax>
Email: <DrEmail>
Provider No.: <DrProviderNo>	

Patient/Client/Consumer details:
Title: <PtTitle>
First name: <PtFirstName> 
Surname: <PtSurname>
Preferred Name: <PtPrefName>
Date of Birth: <PtDoB>   Age: <PtAge>
Sex at Birth: <PtSex>
Gender Identity: <GenderIdentity>
ATSI: <PtEthnicity>

Interpreter required: <Does the patient require an interpreter?>
Preferred language is: <If interpreter needed, which language>
Please consider Telehealth for this patient:
<Please consider Telehealth for this patient:>
Cultural safety requirements: <Cultural safety requirements?>
Access/Support requirements: <Access/Support requirements?>		Address: <PtAddress>
Mobile: <PtPhoneMob>
Email: <PtEmail>
Home Phone: <PtPhoneH>  
Work Phone: <PtPhoneWk>
Preferred method of communication: <Patient's preferred contact method>

Medicare: <PtMCNo> <PtMCLine> Expiry: <PtMCExpiry>
Pension/HCC: <PtPensionNo>
DVA: <PtDVANo>
Insurance: <PtInsFund> <PtInsNo>

NOK/Carer/Alternate contact:
Name: <NOKName>  Phone: <NOKContact>
Relationship: <NOKRelation>

	

Consent to referral: <Consent to referral>  
Consent to share information: <Consent to share information>
Is this a 2nd referral for the same problem: <Is this a 2nd referral for the same problem?>
Usual GP (if not referrer):  <Usual GP (if different to referrer)- Name/Practice>	

WestVic HealthPathways provides guidance in patient assessment, management and referral. 
 			<HealthPathways Barwon guidance in Ax Mx referral>
Statewide Referral Criteria apply for Specialist Clinics Referrals. 
<Statewide Referral Criteria apply for Specialist Clinics Referrals.>	

Reason for referral:
<Reason for referral>

GP expectation from consult/assessment:
<What is your expectation from the pain consult/assessment?>

Pain history:
<Pain History (Type of pain, location, date & mechanism of injury/onset of pain, physical findings)>

Referral criteria:<Referral criteria (Please select applicable below)>

Persistent/chronic pain >3 mnths or newly diagnosed suspected CRPS	<Persistent/chronic pain >3 mnths or newly diagnosed suspected CRPS>	
Pain impacts on Activities of Daily Living	<Pain impacts on Activities of Daily Living>	
Adequate trial of treatment for problem has been trialled in last 12 months 	<Adequate trial of treatment for problem has been trialled in last 12 months>	
Patient at risk of functional or psychological deterioration or medication dependence	<Patient at risk of functional or psychological deterioration or medication dependence>	
Patient willing and able to explore living well with pain and self-management strategies	<Patient willing and able to explore living well with pain and self-management strategies>	
Increased readiness to undertake self-management if patient has completed previous pain program for same issue	<Increased readiness to undertake self-management if patient has completed previous pain program for same issue>	
Patient is not seeking solely intervention/injection/medication review	<Patient is not seeking solely intervention/injection/medication review>	

Details of previous pain management including course & outcome of treatment/s, and change in readiness to participate in pain management program:
 <Details of previous pain management including course & outcome of treatment/s, and change in readiness to participate in pain management program:>

History of alcohol / substance abuse / medication misuse: 
<Hx of alcohol/substance abuse/meds abuse? (If yes please describe)>

History of opiates / drugs of dependence > 8 weeks?:
<Hx of opiates/drugs of dependence> 8 weeks?>

Do you have a Schedule 8 permit?
<Do you have a Schedule 8 permit?>

Psychological status and cognitive function:
<Psychological status and cognitive function ( psych hx, stressors, memory, learning capacity)>

Please provide details of treating psychologist/psychiatrist if applicable:
<Please provide details of treating pyschologist/psychiatrist if applicable:>

Past Medical History:
<PMHActive>

Social History:
<SocialHx>

Family History:
<FamilyHx>

Current Medications:
<CurrentRx>

Alerts:
<Comment>

Allergies:
<Reactions>

Smoking Status:
<SmkStatus>
If smoker, smoking cessation discussed: <If smoker, smoking cessation discussed?>

Investigations/Results:
<Ix>

Electronically signed:  <DrName>