Community Chronic Pain Management Program – Referral Form
Return to <Lead Facilitator Name> on Fax <Lead Facilitator Fax>	          Date: <TodaysDate>
Referrers Details:
Name:	<DrName>	Phone:	<DrPhone>	
 Email:	 <DrEmail>	
 Address:	 <DrAddress>	
Patient Information:
Name:	<PtName>	Phone:	<PtPhoneMob>	
DOB:	<PtDoB>	Email:	<PtEmail>	
 Postal Address:	 <PtFull Address Postal>	
Pain Background:
Area of Pain	<Area of Pain>	
Time frame of pain reporting	<Time frame of pain reporting>	

		 Yes/No	
Red Flags	 Neurological deficits	 <Neurological deficits>	
	 Unexplained bladder or bowel dysfunction	 <Unexplained bladder or bowel dysfunction>	
	 Immunosuppressed	 <Immunosuppressed>	
	 History of cancer	 <History of cancer>	
	 Osteoporotic	 <Osteoporotic>	

		 Yes/No	
Comorbid medical conditions	 Cardiovascular Disease	 <Cardiovascular Disease>	
	 Neurological disorder	 <Neurological disorder>	
	 Diabetes	 <Diabetes>	
	 Depression/Anxiety	 <Depression/Anxiety>	
	 Other	 <Other Comorbid Medical Condition>	
 If yes to any, please provide a  brief description		
Medication:
Please list patient’s current medications and dosage:
<SelectedRx>