Referral form

RAH patient UR number	Date	
Personal information (please print clearly)	
Mr/Mrs/Miss/Ms/Dr/Prof Surname	
Given names	
Previous surnames	
Date of birth	Aboriginal or Torres Strait Islander Status
yes    /    no	
Interpreter required:        yes   /   no	Language:	
Address	
	Postcode	
Tel (home)	Tel (work)	Mobile	

General practitioner details	
Name	
Clinic	
Address	
	Postcode	
Tel	Fax	
Email	
Signature

	

Clinical information	
Spinal area	Cervical		Thoracic		Lumbar			
Symptom duration	0-6 weeks		6-12 weeks		3-9 months		9-18 months		>18 months		
Clinical assessment	Pathology	Radiology	
Midline pain, neck or back		Degenerative arthritis		Moderate canal stenosis		
Pain/numbness – arm or leg 		Low impact trauma		Severe canal stenosis		
Predominant side: right or left		High impact trauma		Foraminal narrowing		
Neurogenic claudication		Congenital		Root compression		
Focal myotomal weakness – arm/leg

Myotomal distribution:		Infection		Spondylolisthesis		
				Instability		
Numbness, perianal and both legs

Dermatomal distribution:  		Neoplastic benign		Deformity		
				Spinal cord compression		
Myelopathy or spasticity		Neoplastic malignant		Cord signal change/syrinx		
None of the above		None of the above		None of the above		

Dominant symptoms:
	Neck		Low back 		Limb (arm/leg)		
Provisional Diagnosis:

Previous Spinal Injections	Response:	
Epidural		Nil		Short-term		Sustained		
Nerve block (foraminal)		Nil		Short term		Sustained		
Facet joint		Nil		Short-term		Sustained		
Pain medication used:
	Simple Analgesia
		Opioids		Neuropathic agents		

Patient Name

Additional Information required:	Office use only (triage)	
Investigations – 
please attach copies of all relevant: 
•	X-rays/scans
•	Specialist reports	Clinical Score		
	Category		
Past Medical History - 
please attach summary of: 
•	Medical history/comorbidities including BMI
•	Current medication list	Date		
	Signature		
	Name and designation		
Form adapted from Shelly et al, A scoring system for effective triage of referrals: Spine Severity Score. The Spine Journal 10 (2010) 697-703.