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Patient Identification
The goal of the chronic pain service is to treat and manage children and teens up to 17 years of age who are experiencing chronic pain that is difficult to explain and/or manage with conventional treatment(s). Patients should always be seen and assessed with full investigations by the appropriate pediatric services prior to the referral to the chronic pain team.
A. INCLUSION CRITERIA:
 0 – 17 years
 Chronic pain, at least three months in duration
 Chronic pain as primary complaint
 Chronic pain which impacts activities of daily living, school attendance, sleep, quality of life
and family functioning
B. CLIENT DEMOGRAPHICS:
Name (last): ______________________________ First: __________________________
Street Address; _________________________
City:___________________________________ Postal Code: ___________________
Home Phone Number: ___________________ Alternate Number: _______________
Date of Birth (day/month/year): ___________
Name of Parent or Guardian(s):_______________________________________________
C. REFERRING PHYSICIAN:
Name: ______________________ Phone: _______________ Fax: ________________
Address: _______________________________________________
________________________________________________
D. PATIENT HISTORY:
1. Current Treatments: Current Medications:
Drug Dosage/Frequency Evaluation/Adjustments
Thank you for your referral. Please fax completed form to (613)738-4815
Form No. 1196 January 2012

Physical Strategies:
Psychological Strategies:
2. Physical Examination: Please mark with an “X” the primary source(s) of pain:
Pain Scores: _______
Pain Descriptors:
tingling cramping exhausting sharp
shooting stabbing aching burning
heavy nagging deep
burning throbbing excruciating
unbearable numb continuous
3. Concurrent Medical Problems: ________________________________________________
___________________________________________________________________________
___________________________________________________________________________
E. OTHER CARE PROVIDERS: Please indicate other relevant consultants and attach a copy of
the respective reports (physiotherapy, psychology, psychiatry, and diagnostic imaging reports).
F. INVESTIGATIONS: (to date/please attach reports):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
2. Labs: _____________________________
G. FUNCTIONAL ASSESSMENT: Briefly describe the impact of chronic pain on the patient and/or
their family: ______________________________________________________________________
_________________________________________________________________________________
H. HOW CAN WE ASSIST? In what ways can we assist with the pain management of your patient?
_______________________________________________________________________________
I. CO-JOINT MANAGEMENT: Will you be willing to co-join tly follow this patient? □ Yes □ No
Date: ________________________ Signature _____________________________
Thank you for your referral. Please fax completed form to (613)738-4815
Form No. 1196 January 2012