PAIN MANAGEMENT
REFERRAL FORM
HOSPITAL USE
Consultant appointment date: ………………………
Date of referral: ……………………………………
Patient NHS No: ……………………………………..
Date of birth: …………………… Age: ……….
Surname: ……………………………………………..
Hospital No: ……………………………………..
Forename: ……………………………………………
Patient’s Telephone No: ……………………….
Address: ………………………………………………
Temporary address (if applicable): ………………
………………………………………………………….
…………………………………………………….
…………………………… Post code: ………………
…………………………………………………….
Referring GP: …………………………………………
Practice Stamp/Address:
Registered GP: ……………………………………….
GP’s Telephone No: …………………………………
GP’s Fax No: …………………………………………
Signature of GP: ………………………………
Has the patient been seen in the Pain Clinic previously?
By whom:
When referred:
Reason for previous assessment:
Past Medical History:
Discharge date:
History of Pain Complaint (including your impression of the pain problem)
Objective of requesting this consultation:
Current Medication:
Past Drug History:
Reason Medication Stopped
Psychiatric / Psychological Problems (current Psychological support if any):
Social History:
Any Other Relevant Information:
For Referrals via Choose and Book please attach the completed proforma to the request.
For paper referral the completed proforma should be addressed to:
Referrals Office, Records Management, Derby Hospitals NHS Foundation Trust,
Uttoxeter Road, Derby, DE22 3NE