Living Well with Persistent Pain in the North

Please fax to: 08 8252 9433
Attention: Pain Clinic Coordinator

Living Well with Persistent Pain Program
Referral form
 PATIENT DETAILS 
Date of Referral: «CUSTOMFIELD|493000|D|Date of referral |D»	Date of Birth:  Patient Demographics.DOB	Gender:    Patient Demographics.Gender	
Title: Patient Demographics.Title	Surname: Patient Demographics.Surname	First Name: Patient Demographics.First Name	Middle Name: 	
Address: 
 Patient Demographics.Full Address	
Daytime contact number:              
Home:  Patient Demographics.Phone (Home)	Work: Patient Demographics.Phone (Work)	Mobile: Patient Demographics.Phone (Mobile)	

PATIENT PRESENTATION

Clinical History: Clinical Details.History List

Current Medication List: LSMDDClinical Details.Medication List	

PAIN MEDICATION HISTORY
Medication previously tried: Medication tried

	

PAIN MANAGEMENT HISTORY
Has the patient previously visited a pain clinic or participated in a pain management program? Pain Clinic

If yes, where and when: Pain Clinic

What other pain management strategies have been tried? Pain strategies

	

I request for my patient to participate in the Living Well with Persistent Pain program which includes: 
Living well 

Information and education on living with persistent pain: Info/education

An individual care plan: Individual care plan

A Program Care Coordinator to support them: Care Coordinator  

PROMPT
As part of this, I would like for my patient (please indicate): 
Please indicate 

To see a GP with a special interest in pain for 12 months, who will develop and implement a care plan for their pain management only: GP 12mth Care Plan 

		OR

To be provided with recommendations for a care plan which I will develop and implement as part of their usual care: Recommendations

As the referring GP, I agree to:
Referring GP

Provide additional patient history as required: Patient history

Respond to requests for additional referrals, including HMRs as required: Requests

Support my patient to implement the recommendations of the program: Support

The patient meets all of the following eligibility criteria:
Eligibility Criteria

Over 18 and living in the northern Adelaide suburbs: Over 18

Experiencing chronic or persistent pain which has lasted for more than 3–6 months: 3-6 months of pain 

Diagnosed with chronic or persistent pain and any other biological causes fully addressed or ruled out: Diagnosed

Unsuited for surgical or urgent pain specialist interventions: Interventions

Not involved in an insurance claim for worker's compensation or other third party: Workers Comp 

Not in a palliative care situation: Palliative care

Able to benefit from improved self-management strategies and skills to optimise ongoing care: Self-management

Suitable for and willing to participate in group education. This is a key component and a commitment to attendance is required for the individual to remain in the program: Group education 

Able to understand written and spoken materials utilised. i.e. has good English language capacity: Oral/written skills 

Prepared to give ongoing informed consent for the collection of de-identified evaluation data: Informed consent 

REFERRING DOCTOR / ORGANISATION DETAILS

**A GP Sign off is mandatory for this referral to be accepted**

Please stamp / insert details:

Doctors Signature:                                                  

Date:Miscellaneous.Date

This referral is valid for 12 months. 

On the receipt of this referral, the patient will be placed on the waiting list and contacted with the details of the Living Well with Persistent Pain Program.

Referrals are addressed upon receipt with all considered equally.        

PATIENT CONSENT:
I understand that this referral is for the provision of pain management services, which include an assessment, the development of a plan for treatment, and education sessions. I agree to be a part of this process with the knowledge that:

My medical history will be shared with the necessary health service providers where relevant:  

The information collected is private and will be kept confidential unless agreed upon: 

My GP has explained to me the reasons for participating in this program: 

I understand that my treatment will be monitored and communicated between my treatment team including my GP: 

All personal information gathered will remain confidential and secure with my treating team: 

Name: ___________________________

Signature:________________________

Date: Miscellaneous.Date