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PainWISE Community Pain Support Program Referral

Phone Helen Pini for further information on 0407 836 366

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PATIENT DETAILS
Patient Name:(Required)
First Last
Date of Birth(Required)

Address
Street Address City State Post Code

Email

Daytime contact number:(Required)
PATIENT PRESENTATION
Clinical History:
PAST HISTORY
Has the patient previously visited a pain clinic or participated in in pain management program?
If yes, specify where and when:
The patient has met ALL the following criteria to be eligible for the program (please tick):(Required)
The patient has persisting pain which has lasted for more than 3-6 months
The patient requires improved self-management strategies and skills to optimise ongoing care
The patient is able to participate in online sessions
The patient is ready to explore change to improve their overall quality of life.
REFERRING GP DETAILS
GP Signature:
Your Name
Your Name
Your Name
GP Name:
First Last
Address
Street Address City State Post Code

Date

REFERRING ALLIED HEALTH PROFESSIONAL DETAILS (if this applies)
AHP Signature:
Your Name
Your Name
Your Name
AHP Name:
First Last
Address
Street Address City State Post Code

Date