REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
PERSISTENT PAIN CLINIC

Prior to referral please consider the Screening and Referral Guide for:
Queensland Health Persistent Pain Management Service
Copy and paste the following web address into your browser to view the Guide:
www.health.qld.gov.au/persistentpain/docs/screenrefer_guide_v2.pdf

Please note: The Interdisciplinary Persistent Pain Centre's involvement will be consultative and time-limited. It is expected the patient's ongoing care will be provided by their
General Practitioner

SEND TO Ian Thong (Pain Specialist)
Outpatient Access and Scheduling Centre
Fax: 07 5687 4497                           OR

Secure Transmission Service via Medical Objects or Healthlink to:
QHEALTH, GOLD COAST HEALTH Outpatients
Outpatient Bookings and Referrals	FROM <DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <PracEmail>
Provider Number: <DrProviderNo>

<TodaysDate>

Dear Dr Thong

SECTION 1 Patient details

RE: <PtFullName>
DOB: <PtDoB>
AGE: <PtAge>

Gender: <PtSex>
Address: <PtAddress>
Home Ph: <PtPhoneH>
Mobile Ph: <PtPhoneMob>
Medicare Number*: <PtMCNo> (*Medicare ineligible patients will incur a consultation fee)	Next of Kin/Alternative Contact: <NOKName>
Next of Kin/Alternative Contact Ph: <NOKContact>
Does patient identify as Aboriginal and/or Torres Strait Islander: <Does pt identify as Aboriginal/Torres Strait Islander>
Interpreter required: <Interpreter required>
If yes, specify language: <If yes, specify language>	

SECTION 2 Reason for referral and additional clinical information

What is the reason for this referral: <Specify main reason for referral>
Please provide provisional diagnosis (if available): <Provisional diagnosis if available>
Please include any symptoms and date of onset (if known): <Symptoms and date of onset if known>
Paste or type relevant history, clinical examination findings and treatment to date if required
SECTION 3 Mandatory clinical information

Duration of pain:<Duration of pain>
Location of pain: <Location of pain>
Nature of pain: <Nature of pain>

Mechanism of injury: <Mechanism of injury>

What medication has been tried: <History of medication tried>
What treatment has been tried: <History of treatment>

Currently receiving treatment from other specialist services for the same problem: <Is pt receiving other specialist tx for same problem>
If yes, please provide details/other relevant information: <If yes, please provide relevant information & details>
History of assessment by another pain service/clinic in the past 2 years: <Has patient been to another pain service in the last 2 yr>
If yes, please provide details/other relevant information: <If yes, please provide relevant information & details>
SECTION 4 Investigations

Please indicate whether the following pre-requisite investigations have been undertaken in order for this referral to be processed and attach the results. Please attach specialist reports/summaries/investigations relevant to the patient's pain condition and psychological status (required prior to entry to the service): i.e. Headache and Back Pain - please attach relevant imaging and neurologist/neurosurgeon reports.

FBC: <FBC> 
E/LFT: <E/LFTs>
ESR: <ESR>
CRP: <CRP>
Vitamin D: <Vitamin D>

If relevant:
Rheumatoid Factor: <Rheumatoid Factor (if relevant)>
Autoimmune Marker: <Autoimmune Marker (if relevant)>

<Ix>
SECTION 5 Duration of referral

Please note this referral will remain valid for 12 months.

When referrals expire, there is an expectation that the referring GP or another GP will review the care of the patient. If the patient still requires specialist care, the GP will then be required to submit a new referral for ongoing care. 

SECTION 6 Social factors and impact on the patient

Consider the impact on employment/education; activities of daily life; ability to care for others; personal safety/frailty; other factors. Please paste or type relevant information.

	

SECTION 7 Medical history including co-morbidities and previous surgical interventions

Alcohol: <AlcHx>
Smoking: <SmkStatus> <SmkHx>
<PMHAll>
Allergies: <Reactions>

Current prescribed medications: <CurrentRx>

History of Alcohol/Substance abuse and/or Medication misuse: <History of Alcohol, Substance, Medication abuse>
If yes, please provide details/other relevant information: <If yes, please provide relevant information & details>

History of Opiates/Drugs of dependence for greater than 8 weeks: <History of Opiates, DOD for greater than 8 weeks>
If yes, have the Drugs of Dependence Unit been notified as per the Controlled Substances ACT: <If yes, has the Drugs of Dependence been notified>

SMOs/VMOs in this Specialist Service

Ian Thong (Pain Specialist)	

 General information about referrals

Queensland Clinical Prioritisation Criteria (CPC) are available for this condition and specialty. These criteria can be viewed by visiting: https://cpc.health.qld.gov.au/

Referral Templates that outline clinical information and investigations required to safely refer your patient into Gold Coast Health can be accessed via: https://www.healthygc.com.au/Health-Care-Professionals/Referral-Templates.aspx