76 Grenville Street, 3rd Floor Toronto, Ontario M5S 1B2 Phone: 416-323-6269 Fax: 416-323- 2666

Form C

Version Date: 21 March 2017

Please fax all three pages of the referral form together with requested imaging and consult to TAPMI Central Intake at 416-323-2666.

Your patient’s referral will be assessed by TAPMI Central Intake and sent to the appropriate site with the next available appointment. TAPMI is a comprehensive virtual network of pain management ser-vices in downtown Toronto. The participating hospitals are:

If you have a site preference for your patient please indicate here:

_____________________________________________________________.

Please note that this may increase your patients wait time.

In the TAPMI model, primary care providers play an active role in the treatment of their patients. The TAPMI team will provide assessment and a care plan for your patients' chronic pain problem. In some cases, treatment may be initiated by TAPMI, however, once stabilized (6– 24 months) the patient will be returned to you for ongoing care, including pharmacotherapy, with our continued support.

TAPMI physicians and nurse practitioners will not take over prescribing permanently.

Please note that a referral may be seen by any health discipline (Doctor, Nurse, Pharmacist, Physiotherapist, Psychologist, Social Worker) in TAPMI.

76 Grenville Street, 3rd Floor Toronto, Ontario M5S 1B2 Phone: 416-323-6269 Fax: 416-323- 2666

Form C

Version Date: 21 March 2017

Interpreter required? Yes No If yes, language required:____________________________________

Alternative Contact Name, Relationship and Number: _________________________________________________

Place sticker with Patient Name and Contact Information Here:

DOB:_______________________________________

Patient Gender:

Female

Male

Transgender

Male to Female

Female to Male

Intersex

To be filled by referring health care provider. Please note: All patients must have a primary care provider

Signature: ______________________________ Billing number:_________________Date: _________________

Estimated pain problem start date ________________________________ YYYY / MM / DD

referring provider contact information

Name________________________________________

Address_____________________________________

____________________________________________

Phone Number________________________________

Urgency Level 1: Optimal wait time 5-10 business days

Patient is palliative with a less than 3 months life expectancy

Urgency Level 2: Optimal wait time 10 business days

Acute intervertebral disc herniation or sciatica (onset in the last 6 months)

Complex Regional Pain Syndrome (onset in the last 6 months)

Post surgical nerve injury (onset in the last 6 months)

Requires chronic pain management prior to surgery (surgery within 6 months)

Suspected early post herpetic neuralgia (onset in the last 6 months)

Traumatic nerve injury (onset in the last 6 months)

Palliative with a 3—12 months life expectancy

More than 200 mg/ day of morphine or equivalent (MEQ) AND one or more of the following:

Concerning aberrant drug related behaviors (altering the route of delivery, accessing opioids from other sources)

Benzodiazepine use

Alcohol consumption

Urgency Level 3: Next available appointment All other types of pain (see page 2)

Date of onset:

________________________

If you are not the primary care provider, please indicate the primary care providers name and contact information below.

primary care provider contact information

Name_______________________________________

Address_____________________________________

____________________________________________

Phone Number________________________________

Patient has radicular pain ? Yes � No

76 Grenville Street, 3rd Floor Toronto, Ontario M5S 1B2 Phone: 416-323-6269 Fax: 416-323- 2666

Form C

Version Date: 21 March 2017

Select and rank the pain problem.

Abdominal Pain Pelvic Pain

Abdominal Pain Chronic Pelvic Pain in Men

Chronic Pancreatitis Endometriosis

Inflammatory Bowel Disease (Crohn’s/Ulcerative Colitis) Interstitial Cystitis

Irritable Bowel Syndrome Pudendal Neuralgia

Head Pain Vulvodynia

Cervicogenic Headache Widespread Pain Disorders

Cluster Headache Central Sensitization/Opioid-induced Hyperalgesia

Migraine Tension Type Headache Fibromyalgia

Occipital Neuralgia Widespread Pain

Temporomandibular Joint Disorder Myofascial Pain Syndromes

Trigeminal Nerve Pain Sickle Cell Disease

Musculoskeletal Pain (Neck & Back) Systemic Exercise Intolerance/Chronic Fatigue

Failed back surgery syndrome Syndrome

Joint Pain, Location: _______________ Opioid Management/ Substance Use

Low Back Pain Aberrant drug related behaviours

Limb Dominant Escalating opioid therapy

Back Dominant Patient interested in tapering

Non mechanical back pain Substance Use Disorder

Sciatica/ Radiating Pain Is the patient aware of the referral?

Neck Pain Yes No

Limb Dominant Please Explain:__________________________

Neck Dominant Other

Myofascial Pain Syndromes Cancer Pain (cancer survivor)

Osteoarthritis Cancer Pain (palliative)

Sacro-iliac Joint Pain Cardiac Pain Conditions

Spinal Stenosis Perioperative (6 months)

Whiplash-associated Disorder Rheumatoid Arthritis

Neuropathic Pain Rheumatological Condition

Complex Regional Pain Syndrome i.e. Systemic Lupus Erythematous (Lupus or SLE)

Multiple Sclerosis Traumatic Brain Injury

Painful Diabetic Neuropathy ________________________________________

Phantom limb pain

Post Stroke Pain

Post Surgical Pain

Post-traumatic or compression-related Neuropathic pain

Shingles and Post herpetic Neuralgia

Traumatic Nerve Injury

Trigeminal Neuralgia and Atypical Facial Pain

76 Grenville Street, 3rd Floor Toronto, Ontario M5S 1B2 Phone: 416-323-6269 Fax: 416-323- 2666

Form C

Version Date: 21 March 2017

Please provide the following relevant clinical Information:

Current medication list

Most relevant pain related consultation note

Referral Letter

Relevant investigations

Type: ______________________________________ Date:______________________________

Type: ______________________________________ Date:_____________________________

Type: ______________________________________ Date:_____________________________

General referral notes:

Purpose of referral:

Consultation/ provide advice

Treatment

Specific service requested:__________________________________________________________

Patient treatment preference (select all that apply):

TAPMI to decide on appropriate program for my patient

Pharmacotherapy recommendations: pain clinics will not take over prescribing permanently

Interventional Therapy

Allied Health/ Self Management

Has this patient been referred to a pain clinic before or are they currently being managed by a pain clinic? �Yes �No

Name of clinic:___________________________________ Date last seen:_________________________

Name of clinic:___________________________________ Date last seen:_________________________

Name of clinic:___________________________________ Date last seen:_________________________

Reason and purpose of this referral:

Does the patient have a serious psychiatric diagnosis that may interfere with interventional management? Yes No Please specify:________________________________________________________________________