Persistent Pain Program: Turning Pain into Gain

Date of Referral:	/	/  	

CLIENT DETAILS

Patient Name:	DOB:	Gender:	
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REFERRER DETAILS

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 GP
 Specialist	Position:	
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Persistent Pain Program: Turning Pain into Gain

PATIENT PRESENTATION

Diagnosis:

 Back pain
 Complex regional pain syndrome
 Endometriosis
 Osteoarthritis	

 Fibromyalgia
 Migraine
 Neck Pain
 Osteoarthritis Other:	
Date of diagnosis (if known):

 	 /	/  		
Clinical History:	
Current treatment or therapy (or attach):	Current medications (or attach):	
Has the client been hospitalised in the past month? If so, please provide details:	

 I confirm that I have obtained verbal consent from the client/legal guardian to refer and provide their personal health information to Black Swan Health for further assessment.	
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