General Practitioner Referal to Neurosurgery Specalist Clinic 
Back and Neck Supporting Clinical Infromation Form
PATIENT INFROMATION	REFERRER DETAILS 	
Western Health UR (if known):	Name: <DrName>	
Name: <PtTitle><PtFullName>	Practice: <Practice>	
Gender: <PtSex>	Address: <UsrAddress>	
DOB: <PtDoB>	Fax: <UsrFax>	
Address: <PtAddress> <PtState>	Phone: <DrPhone>	
Home Ph: <PtPhoneH> Mobile Ph: <PtPhoneMob>	Provider Number: <DrProviderNo>	
Interpreter Required? <Interpreter Required?> Language Preferred:  <Interpreter Language Required>		
Priority signs of neurological symptoms 
Weakness: <neurological symptom: weakness>
If yes, list weak muscle groups: <list weak muscle groups:>	Loss of reflex: <neurological symptom:loss of reflex>
If yes, which reflex: <list which reflex>	
Sensory Loss: <neurological symptom: sensory loss>	Perianal Sensory Loss: <neurological symptom: perianal sensory loss>	
Urinary/Bowel Dysfunction: <neurological symptom: Urinary and/or bowel dysfunction>	Hyper-reflexia: <neurological symptom: hyper-reflexia>	
Plantar Reflex: <neurological symptom: Plantar Reflex>	Ataxia: <neurological symptom:Ataxia>	
Clonus: <neurological symptom: Clonus>		
Please be aware that 90 - 95% of referrals to neurosurgery do not require surgical intervention. Neurosurgery specialty is a surgical clinic.
	
Many types of low back/leg pain and neck/arm pain will respond to CONSERVATIVE treatments. In order to prevent acute pain becoming chronic, these conservative options should be explored first unless the involvement of neurological signs is more profound. The expectation is that treatments have been trailed as part of the management history. 

Treatments trailed as part of management history 	
Exercise: <Management History: Exercise?>	Psysiotherapy: <Management History: Psysiotherapy?>	
Weightloss: <Management History: Weightloss?>
If yes, timeframe: <timeframe of weightloss>	Current Anti-inflammatory Medication: <Management History: Taking anti-inflammatory medication>	
Other: <Management History: Other, please specify:>	
Function Limitations (closest response) 	
Walking: <Function Limitations: Walking Distance>	Sitting Duration: <Function Limitations: Maximum Sitting Duration>	
Sleep Significantly Disturbed: <Function Limitations: Sleep Disturbed?>	BMI: <Function Limitations: BMI Result>	
History of Current Condition (attached referral letter)	
Date of onset: <History of Condition: Date of onset>		
Pain Duration: <History of Condition: Pain Duration>	Pain Score: <History of Condition: Pain Score>	
Neurological involvement: <History of Condition: Neurological involvement>	Radicular arm/leg pain: <History of Condition: Radicular arm/leg pain?>	
Current/Previous Management for this condition: <PMHActive>	
Current Medication: <CurrentRx>