For Backpack service, part of the Pain Management department

Date of referral:  

Patient Details:
Surname:	                                     	Forename(s):     		
Address:		Contact Numbers:	   	
		Patient gives consent for a message to be left on an answer machine or family member regarding an appointment - this will not include any confidential clinical information: 	
		Yes	 No	     	
NHS No:		Date of Birth:		

GP Details:
Referring GP:  		
Practice Address:		
Telephone:				

To be completed by GP:

Current level of function / work

Disability	
  Yes	No	If yes please specify:      

Communication Needs	
  Yes	No	If yes please specify:      
	
Any reason patient might be unsuitable for a group education session?	
  Yes	No	If yes please specify:      
	
PMH/ DH  

Reason for Referral/Clinical Presentation

Low Back Pain Pathway – Start Back Score        /9	
Relevant Investigations and results: 	
  Yes	No	 N/A	If yes state and summary of result:     
	
Has the patient had treatment for this problem previously? 	
  Yes	No	If yes please state when and where:      
	
Does the patient have a specific expectation regarding intervention or treatment?	
 Yes	 No	If yes please specify: