Name and address of patient

First Name
Last Name
Title
Street Address
Address (cont.)
Postcode
Home Phone
Date of birth	-- dd/mm/yy

GP details

Name
Practice
Street Address
Address (cont.)
Postcode
Phone

Date submitted:

-- dd/mm/yy

!!! Red flag referral: Select any of the following options that apply:

Suspicion of malignancy*  Bladder/bowel impairment  Saddle anaesthesia  Other (specify below)          

*eg unremitting night pain    max 60 characters

Other important history (eg recent relevant life events, family history etc)

 max 90 characters

Duration of current episode 0-6 weeks 6-12 weeks 3-6 months > 6 months

Is this the patient's first episode of back pain? Yes No

If No, how long ago was the last episode?

In last episode, did patient receive Rx from:

Not applicable LBP triage service Physiotherapy Rheumatology Orthopaedics Pain Clinic

In last episode, was treatment helpful? Yes No

Is there a history of: (tick any which apply) Malignancy Iritis Inflammatory bowel disease Psoriasis Urethritis

Minor neurology symptoms: (tick any which apply) Pain worse on sneezing/coughing Leg pain Numbness Weakness

Because of this back pain episode: (tick any which apply)

Is the patient unable to work? Is the patient unable to do daily living activities? Does the pain keeps patient awake at night?

Pain location/radiation: (tick any which apply)

Back only Buttock Back of leg above knee Back of leg below knee Front of leg above knee Front of leg below knee
Foot (dorsum) Foot (sole) Bilateral symptoms

Signs: (tick any which apply & indicate SLR if limited) Numbness Weakness Reflex loss 

Passive straight leg raise (degrees)

Any investigations (tick any which apply; please enter result or fax copy of report)

Blood test (ESR) Blood test (alk.phos) X-ray (not normally helpful; may be useful if malignancy or infection suspected)

Current management max 60 characters

Presumptive diagnosis max 60 characters

Thank you. You have now completed the questions.

For internet security reasons this form cannot be submitted directly. You have 2 options:

1. Press the "Print" button in your browser toolbar or right-click your mouse and then from the drop-down menu left-click "Print" . Then please fax the printed form to the Triage Coordinator on 020 8308 5441.

2. Right-click in the form and "Select All". Open a blank Word document and right-click, then "Paste" (or Ctl + V). Then save the document with the name bpref <PatientID> (if the patient is John Smith then the filename will be bpref smithj). This can then be used as your C&B attachment file instead of a referral letter

Office use only:Hospital No

Triage to: Physiotherapy Rheumatology Pain Clinic