REQUEST FOR CONSULTATION
Queensland Collaborative
Virtual Integrated Pain Centre

The Virtual Integrated Pain Centre only accepts category 3 patients, please review the clinical prioritisation criteria.
Copy and paste the following web address into your browser to view the Guide:
https://cpc.health.qld.gov.au/Condition/298/persistent-pain
The Virtual Integrated Pain Centre is accessible for patients in rural and remote QLD locations, referrals received from locations not providing this service will be forwarded onto the closest tertiary pain centre for review.

Please note: The Virtual Interdisciplinary Pain Centre's involvement will be consultative and time-limited. It is expected the patient's ongoing care will be provided by their General Practitioner.

SEND TO QCVIPC Intake hub: Gold Coast Interdisciplinary Persistent Pain centre
Fax: 07 56809539                          OR

Secure Transmission Service via Medical Objects or Healthlink to:
QHEALTH, GOLD COAST HEALTH Outpatients
Outpatient Bookings and Referrals	FROM <DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <PracEmail>
Provider Number: <DrProviderNo>

<TodaysDate>

SECTION 1 Patient details

RE: <PtFullName>
DOB: <PtDoB>
AGE: <PtAge>

Gender: <PtSex>
Address: <PtAddress>
Home Ph: <PtPhoneH>
Mobile Ph: <PtPhoneMob>
Medicare Number*: <PtMCNo> (*Medicare ineligible patients will incur a consultation fee)	Next of Kin/Alternative Contact: <NOKName>
Next of Kin/Alternative Contact Ph: <NOKContact>
Does patient identify as Aboriginal and/or Torres Strait Islander: <Does pt identify as Aboriginal/Torres Strait Islander>
Interpreter required: <Interpreter required>
If yes, specify language: <If yes, specify language>	

SECTION 2 Reason for referral and additional clinical information

What is the reason for this referral: <Specify main reason for referral>
Please provide provisional diagnosis (if available): <Provisional diagnosis if available>
Please include any symptoms and date of onset (if known): <Symptoms and date of onset if known>
Paste or type relevant history, clinical examination findings and treatment to date if required
SECTION 3 Mandatory clinical information

Duration of pain:<Duration of pain>
Location of pain: <Location of pain>
Nature of pain: <Nature of pain>

Mechanism of injury: <Mechanism of injury>

What medication has been tried: <History of medication tried>
What treatment has been tried: <History of treatment>

Currently receiving treatment from other specialist services for the same problem: <Is pt receiving other specialist tx for same problem>
If yes, please provide details/other relevant information: <If yes, please provide relevant information & details>
History of assessment by another pain service/clinic in the past 2 years: <Has patient been to another pain service in the last 2 yr>
If yes, please provide details/other relevant information: <If yes, please provide relevant information & details>
SECTION 4 Investigations

Please indicate whether the following pre-requisite investigations have been undertaken in order for this referral to be processed and attach the results. Please attach specialist reports/summaries/investigations relevant to the patient's pain condition and psychological status: i.e. Headache and Back Pain - please attach relevant imaging and neurologist/neurosurgeon reports.

If relevant:
FBC: <FBC> 
E/LFT: <E/LFTs>
ESR: <ESR>
CRP: <CRP>
Vitamin D: <Vitamin D>
Rheumatoid Factor: <Rheumatoid Factor (if relevant)>
Autoimmune Marker: <Autoimmune Marker (if relevant)>

<Ix>
SECTION 5 Duration of referral

Please note this referral will remain valid for 12 months.

When referrals expire, there is an expectation that the referring GP or another GP will review the care of the patient. If the patient still requires specialist care, the GP will then be required to submit a new referral for ongoing care. 

SECTION 6 Social factors and impact on the patient

Consider the impact on employment/education; activities of daily life; ability to care for others; personal safety/frailty; other factors. Please paste or type relevant information.

	

SECTION 7 Medical history including co-morbidities and previous surgical interventions

Alcohol: <AlcHx>
Smoking: <SmkStatus> <SmkHx>
<PMHAll>
Allergies: <Reactions>

Current prescribed medications: <CurrentRx>

History of Alcohol/Substance abuse and/or Medication misuse: <History of Alcohol, Substance, Medication abuse>
If yes, please provide details/other relevant information: <If yes, please provide relevant information & details>

History of Opiates/Drugs of dependence for greater than 8 weeks: <History of Opiates, DOD for greater than 8 weeks>
If yes, have the Drugs of Dependence Unit been notified as per the Controlled Substances ACT: <If yes, has the Drugs of Dependence been notified>

OFFICE USE ONLY
Referrals will be transferred between all QCVIPC provider sites depending on the patients selected programs

Tertiary Site1:
Date Received:
Triaged Date:
Triage Officer:

Tertiary Site2:
Date Received:
Triaged Date:
Triage Officer:

Tertiary Site3:
Date Received:
Triaged Date:
Triage Officer: