PHYSICIAN ORDERS

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Partners Against Pain
Integrated Pain Services
Chronic Pain Clinic
REQUEST FOR CONSULTATION
Page 1 of 2
Patient Identification
Referral by Physician/Nurse Practitioner Only
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-jointly 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
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