CRPS Service- Referral Form

Please complete the following form to enable us to provide the most efficient service for your patient. Send completed forms by e-mail (if using NHS secure addresses only) or by fax or post. If you have any questions please phone Yvette Hibberd, CRPS Programme Coordinator on 01225 473462

Contact Details Patient Name NHS/CHI No DoB Phone Address

Referrer Name Position Address Phone

Patient’s GP Name Practice (if not referrer) Address Phone

Checklist Affected region(s) Has the patient been given a confirmed diagnosis of CRPS? Yes / No If yes : By whom: Date of diagnosis/duration of symptoms: What was the trigger to CRPS onset?

If no: How long has the patient experienced signs and symptoms suggestive of CRPS?

Does the patient exhibit any movement disorders (eg, dystonia, myoclonus) of the affected part ?

Referral Form-V1-12-7-11. Date of review: Dec 2011 1 Current and Previous Management Medications Please list current medications for CRPS (dose, date started)

Please list previous medications for CRPS and the reason for stopping

Invasive treatments (please list type(eg, sympathetic blockade), date and location)

Therapy (please list therapy interventions and outcome)

Other healthcare professionals Please list the names and contact details of all healthcare professionals still involved in the patient’s care.

Other relevant information: Please highlight any other relevant information (eg, Current & PMH, other medication, psychosocial issues, litigation) Current & PMH

Non-CRPS Medication

Psychosocial Issues

Litigation Does the patient have ongoing litigation resulting from CRPS Yes/ No / Don’t know

Referral Completed by: Name: Signature (if sent by fax or post)

Referral Form-V1-12-7-11. Date of review: Dec 2011 2 Position: Date:

Please enclose copies of all letters from other healthcare professionals which are relevant to this referral.

Please RETURN the form via: e-mail: [email protected] (only send from a secure NHS address) fax: 01225 473461 (safe haven fax) post: CRPS Service. Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK

Referral Form-V1-12-7-11. Date of review: Dec 2011 3