General Practitioner Referral to Neurosurgery Specialist Clinic Back and Neck Supporting Clinical Form 
PATIENT DETAILS	REFERRER DETAILS	
Western Health UR (if known:) Patient Details:	Name: Treating Doctor.Name	
Name: Patient Demographics.Full Name	Practice: Practice.Name	
Gender: Patient Demographics.Gender	Address: Practice.Address	
DOB: Patient Demographics.DOB	Fax: Practice.Fax Phone: Practice.Phone	
Home Ph:Patient Demographics.Phone (Home) Mobile Ph: Patient Demographics.Phone (Mobile)	Provider Number: Treating Doctor.Provider Number	
Interpreter Required: Patient Details
If yes, preferred language: Patient Details:		

Priority Signs of Neurological Symptoms 	
Weakness: Neurological Symptom
If yes, list weak muscle groups: Neurological Symptom	Sensory Loss: Neurological Symptom	
Urinary/Bowel Dysfunction: Neurological Symptom	Perianal Sensory Loss: Neurological Symptom	
Loss of Reflex: Neurological Symptom
If yes, which reflex: Neurological Symptom	Ataxia: Neurological Symptom	
Plantar Reflex: Neurological Symptom	Clonus: Neurological Symptom	

Please be aware that 90 - 95% of referrals to neurosurgery do not require surgical 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 trailed as part of the management history. 
Treatments have been trailed of the management history 	
Exercise: Trailed Treatment	Weight loss: Trailed Treatment:
If yes, please specify timeframe: Trailed Treatment:	
Physiotherapy: Trailed Treatment:	Anti-inflammatory medication: Trailed Treatment:	
Other, please specify: Trailed Treatment:	
Functional Limitations: (Closest response) 	
Walking: Functional Limit	Sitting Duration: Functional Limits:	
Sleep significantly disturbed: Functional Limit	BMI: Functional Limits:	
History of Current Condition (attached referral letter)	
Date of onset: Condition History 	Pain Score: Condition History: 
Pain duration: Condition History: 	
Radicular arm/leg pain: Condition History: 	Neurological involvement: Condition History: 	
Current/previous management for this condition: Clinical Details.Past History	
Current Medication: Clinical Details.Medications - Current Short Term