Patient First Name Patient Last Name Patient's Phone Number Patient's Email Date of birth Referrer Title Referrer First Name Referrer Last Name Referrer Type GPMedical specialistOccupational TherapistPhysiotherapistOccupational NurseSurgeonOther Referrer Practice Name Referrer Practice Number Referrer Email 1. How long have you had your current pain problem? Tick one. 0-1 week1-2 weeks3-4 weeks4-5 weeks6-8 weeks9-11 weeks3-6 months6-9 months9-12 monthsOver 1 year 2. How would you rate the pain that you have had during the past week? ( 0 = No Pain | 10 = Pain as bad as it could be) 012345678910 3. I can do light work (or home duties) for an hour. ( 0 = Not at all | 10 = Without any difficulty) 012345678910 10 - X 4. I can sleep at night. ( 0 = Not at all | 10 = Without any difficulty) 012345678910 10 - X 5. How tense or anxious have you felt in the past week? ( 0 = Absolutely calm and relaxed | 10 = As tense and anxious as I’ve ever felt) 012345678910 6. How much have you been bothered by feeling depressed in the past week? ( 0 = Not at all | 10 = Extremely) 012345678910 7. In your view, how large is the risk that your current pain may become persistent? ( 0 = No risk | 10 = Very large risk) 012345678910 8. In your estimation, what are the chances you will be working your normal duties (at home or work) in 3 months? ( 0 = No chance | 10 = Very large chance) 012345678910 10 - X 9. An increase in pain is an indication that I should stop what I’m doing until the pain decreases. ( 0 = Completely disagree | 10 = Completely agree) 012345678910 10. I should not do my normal work (at work or home duties) with my present pain. ( 0 = Completely disagree | 10 = Completely agree) 012345678910 Total Assessment score Other Relevant information (or N/A) BackNext Please fill out the additional details below to generate a completed ACC6273 Provider referral for pain management form. This form will be attached to the automated email you receive once you have pressed submit. 1. Client details ACC claim number NHI number Mobile Number Postal address (If different from above) Known barriers or special considerations Please note details, eg if a barrier, note any existing or recommended support Cultural or language considerations:Selected Substance abuse:Selected Other health issues:Selected On current medication:Selected Other:Selected None:Selected 2. Referrer details Phone number Preferred method of contact: Phoneemail 3. ACC contact details (if known) ACC contact person: ACC branch: Contact phone number: Email address: 4. Why I’m making this referral Please let us know why you’re making this referral for the Pain Management service. Include advice on how the clients current pain concern is linked to covered injury(s) 5. Service level required Please let us know the type of service required. Service level The Pain Management Service supplier will contact ACC to seek approval Community services:Selected Please send a copy of all reports to ACC Tertiary services:Selected Please provide all supporting medical information available Group education:Selected Please send a copy of any reports 6. Injury details Injury description: Date of injury: Read code Description Side Site How did this injury happen (mechanism of injury)? 7. Injury management and rehabilitation Describe the management and rehabilitation provided to date. Type and number of treatments: Current assistance: Current daily activities: Barriers or obstacles to return to work: Relevant client specific issues: 8. Relevant contact details Please list who was involved with this client’s rehabilitation. Role Contact person’s name Phone number Email address Treating General Practitioner (GP) Employer or school Specialist Physiotherapist Psychologist Other 9. Attached documents Please list all the documents you’re attaching to this referral. For example clinical notes, radiology reports etc.
