Chronic Pain Management Programme REFERRAL FORM In order to avoid delay please complete all sections, ensuring all criteria are met and enclose an up to date medical summary PATIENT DETAILS: Title: Address: Name: Postcode: Date of Birth: Telephone: NHS No. GP Name & Address: Date of referral: Ethnicity: Referral Criteria Yes Referred by:- Hertfordshire GP or Consultant who has seen them for their pain Aged 18 or above. (Patients between the ages of 16-18 can be referred as long as they are not in full time education) Chronic non-malignant pain of at least 6 months duration that is not associated with any new significant acute signs and symptoms Persistent Pain in spite of all appropriate Medical treatment The patient is not experiencing other acute signs and symptoms Pain is the Primary Problem for the individual at this time with one or more of the following: Reduced sense of control over life/ loss of self confidence Reduced quality of life Reduced fitness & activity levels Distressed by pain - disturbance The patient is not waiting for further surgical and medical investigation or treatment The patient is not diagnosed with severe or enduring mental health conditions The patient is not currently receiving care from Mental Health Services The patient is not abusing alcohol and or using illicit drugs The patient is ready to consider a self management approach The patient is able to travel to and from the outpatient clinic Reason for referral: Why do you think the chronic pain management programme could be beneficial to the patient at this time?
Chronic Pain Management Programme REFERRAL FORM In order to avoid delay please complete all sections, ensuring all criteria are met and enclose an up to date medical summary PATIENT DETAILS: Title: Address: Name: Postcode: Date of Birth: Telephone: NHS No. GP Name & Address: Date of referral: Ethnicity: Referral Criteria Yes Referred by:- Hertfordshire GP or Consultant who has seen them for their pain Aged 18 or above. (Patients between the ages of 16-18 can be referred as long as they are not in full time education) Chronic non-malignant pain of at least 6 months duration that is not associated with any new significant acute signs and symptoms Persistent Pain in spite of all appropriate Medical treatment The patient is not experiencing other acute signs and symptoms Pain is the Primary Problem for the individual at this time with one or more of the following: Reduced sense of control over life/ loss of self confidence Reduced quality of life Reduced fitness & activity levels Distressed by pain - disturbance The patient is not waiting for further surgical and medical investigation or treatment The patient is not diagnosed with severe or enduring mental health conditions The patient is not currently receiving care from Mental Health Services The patient is not abusing alcohol and or using illicit drugs The patient is ready to consider a self management approach The patient is able to travel to and from the outpatient clinic Reason for referral: Why do you think the chronic pain management programme could be beneficial to the patient at this time?
Chronic%20Pain%20Management%20Service%20Referral%20Form%20V2.docx