Referral Form
Community Chronic Pain Management Program – Referral Form
Return to <<Insert Lead Facilitator Name>> on Fax <<Lead Facilitator Fax Number>>	            Date: <<Miscellaneous:Date>>
Referrers Details:
Name:	<<Doctor:Name>>	Phone:	<<Doctor:Phone>>	
 Email:	 <<Doctor:E-mail>>	
 Address:	 <<Doctor:Full Address>>	
Patient Information:
Name:	<<Patient Demographics:Full Name>>	Phone:	<<Patient Demographics:Phone (Mobile)>>	
DOB:	<<Patient Demographics:DOB>>	Email:	<<Patient Demographics:E-mail>>	
 Postal Address:	 <<Patient Demographics:Full 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:
<<Clinical Details:Medication List>>