PAIN CLINIC REFERRAL FORM
Concord Hospital  
RPA Hospital
Fax No: CRGH: 9767 7841
Fax No: RPAH: 9515 9831
		
Name:	<PtName>	
Address:	<PtAddress>	
E-mail	<PtEmail>	
Phone:	<PtPhoneMob><PtPhoneH>		
Date of Birth:	<PtDoB>		
ATSI	Aboriginal	Torres Strait Islander	Neither	
CALD Status Yes/No	Language Spoken at Home

	Interpreter Required	Yes/No	

Referring GP Details 	
GP Name:_<DrName>	Phone No:<DrPhone>	
Address:<DrAddress>	Fax No:<DrFax>	
e-mail: <DrEmail>	

Reason for referral- Please tick the relevant box(es)	
All reasonable investigations pertaining to pain have been carried out	¨	
Reasonable and accessible management in the primary care sector has been carried out	¨	
Pain has significant impact on life
•	 Sleep, self-care necessitating the assistance of others
•	 Mobility, work, school attendance, recreation, relationship and/or other emotions	
¨

¨	
Emergency Department presentations or hospital admissions for pain 	¨	
Complex psychosocial influences relating to pain behaviour requiring specialised assessment and care 	¨	
History of addiction or prescribed medication use complicating current management e.g. escalating opioid requirement	¨	
Difficult to control neuropathic pain 	¨	
Difficult to control cancer pain	¨	
Persistent pain following trauma or surgery where there is concern regarding transition to chronic pain	
¨

¨	
Location of pain:……………………………………………………………………………………..

Impact of Pain:………………………………………………………………………………………
	
Priority Category 	Wait Time <8 weeks ¨	Wait time 2-6 months ¨	Wait time 6-12 months ¨	

Please ensure specialist reports/summaries/investigations relevant to the patient’s pain condition are attached	

Patient history	
Relevant clinical history

<PMHActive>

	
Background surgical and imaging history (please attach relevant reports)  

	
Current treatment from other specialist or allied health professional for the same problem? 
Aware and supportive of referral?
Please provide details

	Yes/No	
History of assessment by another pain service or rehabilitation service for pain management in the last 2 years?

Name of Service:

Please attach relevant correspondence

	Yes/No	
Current Medications (include dosage route, frequency and include analgesics)
<CurrentRx>		

Psychiatric history?
Please describe

Psychological stressors
Please describe

Have any addiction services been involved?
Please provide details

	¨

¨

Yes/No

	
Has the patient consented to the referral?	Yes/No	
Does the patient require an advocate/parent/guardian to be involved in consultations and management
If yes: Relationship to patient:………………………………………………………….

Name:……………………………………………………………………………………..

Contact Details:…………………………………………………………………………………..

Has carer strain been identified?	Yes/No

	
Would you like the relevant pain service to contact you for telephone advice as soon as possible?

	Yes/No	

*Referral to parallel services such as addiction medicine, psychiatry and mental health may be essential

GP Signature:  ________________________ 			
Date:<TodaysDate>

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)