Is this a request for Radiofrequency denervation for chronic low back pain? YES NO Where is the main source of pain coming from? Please specify: (e.g. structures supplied by medial branch nerve) The patient received a diagnostic Medial branch block? YES NO What was the duration of relief? Is this for Spinal decompression for sciatica? YES NO Please specify: Laminectomy Foraminotomy Undercutting facetectomy Discectomy Please provide a copy of confirmed diagnosis. Details of historic pain - Please note requests will only be considered if the patient has had documented pain in the long term, i.e. one year and over. How long has the patient been managing with the symptoms? Has the patient been assessed by a multi-disciplinary pain management team? YES NO Does the patient have localised back pain? YES NO Cause of Pain: Type of Pain: Duration of Pain: Severity of Pain: Conservative Measures Please detail which non-drug treatments and conservative measures have been tried Completed weight loss program (where applicable) Exercise Physiotherapy Self-management Please provide specific details: Are the symptoms persistent and do they significantly interfere with YES NO patient’s activities of daily living? Please indicate: Work-related issues Light duties because of the condition – Work-related issues Off work/missed work/ unable to work due to condition – Domestic activities Carer activities What drugs have been tried for this condition? Drug Dose Date Date Outcome & Reason for Stopping /Continuing Started Stopped (e.g. state the side effect, if it did not work or reason (approx.) (approx.) for continuing)
Is this a request for Radiofrequency denervation for chronic low back pain? Where is the main source of pain coming from? Please specify: (e.g. structures supplied by medial branch nerve) YES NO The patient received a diagnostic Medial branch block? YES NO What was the duration of relief? Is this for Spinal decompression for sciatica? Please specify: Laminectomy Foraminotomy Undercutting facetectomy Discectomy YES NO Please provide a copy of confirmed diagnosis. Details of historic pain - Please note requests will only be considered if the patient has had documented pain in the long term, i.e. one year and over. How long has the patient been managing with the symptoms? Has the patient been assessed by a multi-disciplinary pain management team? YES NO Does the patient have localised back pain? YES NO Cause of Pain: Type of Pain: Duration of Pain: Severity of Pain: Conservative Measures Please detail which non-drug treatments and conservative measures have been tried Completed weight loss program (where applicable) Exercise Physiotherapy Self-management Please provide specific details: Are the patient’s symptoms persistent and do they significantly interfere with activities of daily living? Please indicate: Work-related issues – Light duties because of the condition Work-related issues – Off work/missed work/ unable to work due to condition Domestic activities Carer activities YES NO What drugs have been tried for this condition? Drug Dose Date Started (approx.) Date Stopped (approx.) Outcome & Reason for Stopping /Continuing (e.g. state the side effect, if it did not work or reason for continuing)