REQUEST FOR PAIN MANAGEMENT APPOINTMENT 
ReferralNet: (BH Outpatients)
FAX: 03 4215 1383
							
GP Referral
		Referral Date: Miscellaneous.Date
Feedback Requested:  Feedback requested

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?  Telephone advice		Referring General Practitioner:
Name:Treating Doctor.Name
Practice: Practice.Name
Address:Practice.Address
Phone:  Practice.Phone
Fax:  Practice.Fax
Email: Treating Doctor.E-mail
Provider No.: Treating Doctor.Provider Number	

Patient/Client/Consumer details:
Title: Patient Demographics.Title
First name: Patient Demographics.First Name
Surname: Patient Demographics.Surname
Preferred Name: Patient Demographics.Popular Name

Date of Birth: Patient Demographics.DOB          Age: Patient Demographics.Age
Gender: Patient Demographics.Gender 

ATSI: Patient Demographics.ATSI Status
Interpreter required: Interpreter
Preferred language is: Preferred language
Please consider Telehealth for this patient: Telehealth 
Cultural safety requirements: Cultural Safety
Access/Support requirements: Access/Support		Address: Patient Demographics.Full Address
Mobile: Patient Demographics.Phone (Mobile)
Email: Patient Demographics.E-mail
Home Phone: Patient Demographics.Phone (Home)
Work Phone: Patient Demographics.Phone (Work)
Preferred method of communication: Preferred contact 

Medicare: Patient Demographics.Medicare Number  Expiry: Patient Demographics.Medicare Expiry Date
Pension/HCC: Patient Demographics.Pension Number
DVA: Patient Demographics.DVA Number
Insurance: Patient Demographics.Health Fund NamePatient Demographics.Health Fund Member Number

NOK/Carer/Alternate contact:
Name: Patient Demographics.NOK Name  
Phone: Patient Demographics.NOK Mobile Phone
Relationship: Patient Demographics.NOK Relationship

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

WestVic HealthPathways provides guidance in patient assessment, management and referral. 
HealthPathways
Statewide Referral Criteria apply for Specialist Clinics Referrals. 
Referral criteria	

Reason for referral:
Reason for referral

GP expectation from consult/assessment:
GP expectation

Pain history:
Pain history

Referral criteria: Referral criteria

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

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

History of alcohol / substance abuse / medication misuse: 
Hx Substance abuse 

History of opiates / drugs of dependence > 8 weeks?:
Opiate use >8wks

Do you have a Schedule 8 permit?
Sch 8 permit

Psychological status and cognitive function:
Psychological status

Please provide details of treating psychologist/psychiatrist if applicable:
Treating clinican 

Past Medical History:
Clinical Details.Past History

Social History:
Clinical Details.Social History

Family History:
Clinical Details.Family History

Current Medications:

Clinical Details.Medication List

Alerts:
Clinical Details.Warnings

Allergies:
Clinical Details.Allergies

Alcohol History:
Clinical Details.Alcohol

Smoking Status:
Clinical Details.Smoking
If smoker, smoking cessation discussed: Smoking cessation

Investigations/Results:
Clinical Details.Result List (Selected)

Electronically signed by: Treating Doctor.Name