General Practitioner Referral to Neurosurgery Specialist Clinic Back and Neck Supporting Clinical Form
PATIENT INFORMATION
Western Health UR (if known):	REFERRER DETAILS:	
Name: <<Patient Demographics:Full Name>>	Name:<<Doctor:Name>>	
Gender: <<Patient Demographics:Sex>>
DOB:<<Patient Demographics:DOB>>	Practice:<<Practice:Name>>	
Address:<<Patient Demographics:Full Address>>	Address: <<Practice:Address>>	
Home Ph: <<Patient Demographics:Phone (Home)>>
Mob Ph: <<Patient Demographics:Phone (Mobile)>>	Fax:<<Practice:Fax>> 
Phone:<<Practice:Phone>>	
Interpreter Required?<<Patient Demographics:Requires Interpreter>>
Language Preferred:<<Patient Demographics:Language Preferred>>	Provider Number: <<Doctor:Provider Number>>	
Priority Signs of Neurological Symptoms 
Sensory<<Neurological Symtom: Sensory Loss>>	Weakness: <<Neurological Symtom: Weakness>>
If yes, list weak muscle groups: <<If yes, list Muscle Groups: >>	
Urinary/Bowel Dsyfunction:<<Neurological Symtom: Urinary/Bowel Dysfunction>>	Perianal Sensory Loss:<<Neurological Symtom: Perianal Sensory Loss >>	
Loss of Reflex:<<Neurological Symtom: Loss of Reflex>>
If yes, which reflex? <<If yes, what reflex?>>	Hyper-reflexia:<<Neurological Symtom: Hyper-reflexia>>	
Antaxia:<<Neurological Symtom: Ataxia >>	Plantar Reflex:<<Neurological Symtom: Plantar Reflex>>	
Clonus: <<Neurological Symtom: Clonus>>		
 
	Please be aware that 90-95% of referrals to neurosurgery do not require intervention. Neurosurgery speciality 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 trailledtrailed of the management history. 
Treatments have been trialled as part of management history	
Exercise: <<Trailed treatment: Exercise >> 	Psysiotherapy: <<Trailed treatment: Physiotherapy >>	
Weightloss: <<Trailed treatment: Weight loss >> 
If yes, timeframe: 	Anti-inflammatory medication: <<Trailed treament: Anti-inflam medication>>	
Other, please specify: <<Trailed Treatment: If other, specify >>	If yes, timeframe: <<Anti-inflamatory medication, timeframe: >>	
Function Limitations (closest response:) 	
Walking:<<functional limitation: Walking >>	Sitting Duration:<<Function Limitation: Sitting duration >>	
Sleep SignifcanSignificantlyd: <<functional limitation: Sleep disturbed>>	BMI:<<Patient BMI: >>	
History of Current Condition (attached referral letter) 	
Date of onset: <<History of current condition: onset date>>	Pain Score: <<History of condition: Pain score>>
 Duration: <<Duration of pain: >>	
Radicular arm/leg pain: <<Condition history: Radicular arm or leg pain>>	Neurological involvement: <<condition history: Neurological involvement >>	
Current/Previous Management for this condition: <<Management of previous condition: >>	
Curent MeCurrenton:<<Clinical Details:Medication List>>