<p>CRPS Service- Referral Form</p><p>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 </p><p>Contact Details Patient Name NHS/CHI No DoB Phone Address</p><p>Referrer Name Position Address Phone</p><p>Patient’s GP Name Practice (if not referrer) Address Phone</p><p>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?</p><p>If no: How long has the patient experienced signs and symptoms suggestive of CRPS?</p><p>Does the patient exhibit any movement disorders (eg, dystonia, myoclonus) of the affected part ?</p><p>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)</p><p>Please list previous medications for CRPS and the reason for stopping</p><p>Invasive treatments (please list type(eg, sympathetic blockade), date and location)</p><p>Therapy (please list therapy interventions and outcome)</p><p>Other healthcare professionals Please list the names and contact details of all healthcare professionals still involved in the patient’s care.</p><p>Other relevant information: Please highlight any other relevant information (eg, Current & PMH, other medication, psychosocial issues, litigation) Current & PMH</p><p>Non-CRPS Medication </p><p>Psychosocial Issues</p><p>Litigation Does the patient have ongoing litigation resulting from CRPS Yes/ No / Don’t know</p><p>Referral Completed by: Name: Signature (if sent by fax or post)</p><p>Referral Form-V1-12-7-11. Date of review: Dec 2011 2 Position: Date: </p><p>Please enclose copies of all letters from other healthcare professionals which are relevant to this referral.</p><p>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</p><p>Referral Form-V1-12-7-11. Date of review: Dec 2011 3</p>