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

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 Treating Doctor.Name
Practice.Name
Practice.Address
Phone: Practice.Phone
Fax: Practice.Fax
Email: Treating Doctor.E-mail
Provider Number: Treating Doctor.Provider Number

                  
Miscellaneous.Date

SECTION 1 Patient details

RE: Patient Demographics.Full Name
DOB: Patient Demographics.DOB
AGE: Patient Demographics.Age

Gender: Patient Demographics.Gender
Address: Patient Demographics.Full Address
Home Ph: Patient Demographics.Phone (Home)
Mobile Ph: Patient Demographics.Phone (Mobile)
Medicare Number*: Patient Demographics.Medicare Number  (*Medicare ineligible patients will incur a consultation fee)	Next of Kin/Alternative Contact: Patient Demographics.NOK Name
Next of Kin/Alternative Contact Ph: Patient Demographics.NOK Mobile Phone
Does patient identify as Aboriginal and/or Torres Strait Islander: Does pt identify as 
Interpreter required: Interpreter required
If yes, specify language: If yes, specify lang	

SECTION 2 Reason for referral and additional clinical information

What is the reason for this referral: Specify reason

Please provide provisional diagnosis (if available): Provisional diag

Please include any symptoms and date of onset (if known): Symptoms and date

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 (if applicable): Mechanism of injury

What medication has been tried: Hx medication
What treatment has been tried: Treatment Tried

Currently receiving treatment from other specialist services for the same problem: Current treatment
If yes, please provide details/other relevant information: Treatment details

History of assessment by another pain service/clinic in the past 2 years: Another pain service
If yes, please provide details/other relevant information: Pain service details

SECTION 4 Investigations

Please indicate whether the following investigations have been undertaken in order for this referral to be processed and attach the results. In addition, please also attach any investigation results you consider to be relevant such as any previous reports or relevant letters from previous pain management.

If relevant:
FBC: FBC
E/LFT: E/LFTs
ESR: ESR
CRP: CRP
Vitamin D: Vitamin D
Rheumatoid Factor: Rheumatoid Factor
Autoimmune Marker: Autoimmune Marker

Please attach specialist reports/summaries, investigations relevant to the patient's pain condition and psychological status (required prior to entry to the service): i.e. Headache and Back Pain - please attached relevant imaging and neurologist/neurosurgeon reports.

Clinical Details.Result List (Selected)

SECTION 5 Duration of referral

Please note that 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: Clinical Details.Alcohol
Smoking: Clinical Details.Smoking

Clinical Details.Problem List (Current) With Comments

Clinical Details.Problem List (Resolved) With Comments

Allergies: Clinical Details.Allergies

Current prescribed medications: Clinical Details.Medications - Current Regular

History of Alcohol/Substance abuse and/or Medication misuse: Substance history
If Yes please provide details/other relevant information: Substance details

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