PERSISTENT PAIN MANAGEMENT SERVICE REFERRAL FORM

Referral to
Dr Matthew Bryant
North Queensland Persistent Pain Management Service
The Townsville Hospital
100 Angus Smith Drive
PO Box 670, Douglas  Qld  4814
Phone: (07) 4433 2218 | Fax: (07) 4433 2223

Patient Details
Family Name: <PtSurname> Given Name: <PtFirstName> 
Address: <PtAddress>
Ph H: <PtPhoneH>  W: <PtPhoneWk>  M:<PtPhoneMob> Email: <PtEmail>
Sex:  <PtSex> DoB: <PtDoB>
Marital status: <PtMaritalSt>  

Medicare No:<PtMCNo> <PtMCLine>  
Ethnicity: <Ethnicity>  <Other ethnic group>
Is an Interpreter required?    <Is an interpreter required?>    If required, what language? <If required, what language> 

Referring GP
<DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>   Fax: <UsrFax>   Email: <DrEmail>

Mandatory Information:
•	reason for referral (summary of patient's needs) 
•	date of injury/onset of pain
•	mechanism of injury (if applicable)
•	location and nature of pain Provisional diagnosis (if determined)
•	history of treatment for pain
•	past analgesia/medication trialled for pain condition
•	history of assessment by another pain service/clinic
•	current treatment from/referral to other specialist service for the same pain problem
Please ensure specialist reports/summaries/investigations relevant to the patient's pain condition and psychological status are attached.

Reason for Referral (Summary of patient's needs and pain history): 
<Reason for Referral (Summary of pt's needs and pain history)>
Relevant Clinical History: 
<SelectedPMH>
History of alcohol/substance abuse and / or medication misuse? 
<History of substance abuse / medication misuse?> 
If yes, please provide details. 
<If yes, please provide details.>
History of opiates/drugs of dependence >8 weeks?  
<History of opiates/drugs of dependence >8 weeks?>
If yes, please provide details:  
<If yes, please provide details:>
Have you notified the Drugs of Dependence Unit as per the Controlled Substances Act? 
<Have Drugs of Dependence Unit been notified?>
Please provide details:  
<Please provide details:>
Psychological Stressors: 
<Psychological Stressors: (if known)>
Psychiatric History: 
<Psychiatric History: (if known)>
Cognitive Function: 
<Cognitive Function: (if known)>
Social History: 
<SocialHx>
Family History: 
<FamilyHx>
Current Medications:  
<SelectedRx>
Recent Investigation Results:   
<Ix>
Allergies 
<Reactions>

This patient's pain has been appropriately assessed and he/she is medically fit to undertake a pain management program.(Please indicate)	Yes/No	
I only require telephone advice to help manage this patient.:  (Please indicate)
(You will be contacted regarding this option.)	Yes/No	
This patient consents to this referral.: (Please indicate)	Yes/No	
Signed:

		<TodaysDate>
<DrName> 

OFFICE USE ONLY
	Referral received:	Triage date:	Triage officer name:	Signature	
URGENCY	
	Category 1(<30 days)		Category 2(<90 days)		Category 3(<365 days)		GP contact/phone advice	
	Inappropriate referral		Further information required; (Specify)...............................................................................................	
SERVICE TYPE:	
	Medical Consultation (specify):.		Multidisciplinary team review (specify):	
				
	Allied Health (specify)		Pain Management Program (specify)	
				
	Orientation – education program: (specify)		Other (specify)