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Pain Clinic Referral Form - The Ottawa Hospital

Pain Clinic Referral Form - The Ottawa Hospital 2025

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The document is a referral form for a pain clinic, requiring detailed patient information including personal details, medical history, and consent for treatment. It outlines the roles of the referring clinician and primary care provider, emphasizes the importance of ongoing support from the PCP, and describes the clinic's interprofessional approach to managing chronic pain. The form also includes sections for documenting pain diagnoses, previous treatments, and patient needs.

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Click ‘Get Form’ to open the Pain Clinic Referral Form in the editor.
Begin by filling in the patient's personal information, including Name, Address, Phone number, and Date of Birth. Ensure accuracy as this information is crucial for processing the referral.
In Section A, provide a detailed medical history. Attach all relevant reports regarding pain conditions, current medications, and previous treatments. This section is vital for understanding the patient's background.
Proceed to Section B to document any other pain-related assessments or treatments. Indicate if the patient has attended a Chronic Pain Community self-management program or received treatment from another Pain Clinic.
In Section C, specify pain diagnoses and duration of the pain condition. Check all applicable boxes from the referral criteria to ensure comprehensive evaluation.
Finally, complete Section D by noting any patient needs such as preferred name, gender, communication requirements, and barriers to care. This information helps tailor support for the patient.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Why am I being referred to a pain management clinic?

Chronic Pain Generally speaking, pain is classed as chronic if it continues for over a period of three months. This category of pain incorporates: nerve pain, pelvic pain, abdominal pain, pain involving the joints and spine, cancer pain, post-surgery pain, and unusual pain in the limbs.

Do I have to have a referral to see a pain management doctor?

In many situations, it makes sense to get a referral from your primary care physician before you go to a pain management specialist. But every situation is unique so you might be able to visit the pain management doctor without a referral.

What happens when you are referred to a pain clinic?

Your appointment with a pain management doctor will likely last around an hour. Youll discuss your medical history and current pain symptoms. The pain management doctor will perform a physical exam and possibly order tests. The doctor may order tests such as blood work or an MRI to help diagnose the pain.

How do I prepare for my first pain clinic visit?

Preparing for the Visit If you have a history of pain, gather all relevant medical records, including past diagnoses, medications, and treatment history. Identify the location of the pain to describe it accurately to your specialist. Its important to track both the intensity and duration of your pain.