Prtsmuth Persistent Pain Service Lng Term Cnditins Suite Grund Flr, Blck A St Mary s Cmmunity Health Campus Miltn Rad Prtsmuth Hampshire PO3 6AD Tel: 23 9268 485 Fax: 23 9268 21 Dear GP Instructins regarding referral f patients t the Persistent Pain Service The Persistent Pain Service manages patients wh have a histry f unremitting persistent chrnic pain and are increasingly disabled and distressed. They will have had pr utcmes fllwing primary care physitherapy and/r medical interventins. In rder fr us t accept a referral frm yu (paperwrk is available t yu via http://nww.pip.prtsmuthccg.nhs.uk) all f the fllwing needs t be enclsed: The referral prfrma Patient cmpleted psychmetric questinnaires (BPI, GAD-7, PHQ-9 and PSEQ) A cnfirmed diagnsis f Chrnic Pain Any supprting dcumentatin and/r crrespndence frm the fllwing departments: Pain Clinic, Rheumatlgy, Orthpaedics, Neurlgy, Cardilgy, Respiratry, Psychiatry, Psychlgy, Adult Mental Health, Child and Adlescent Mental Health Services Clinical summary f full medical histry and details f medicatin Once this is cmpleted, please fax the referral t 23 9268 21, r email t SNHS.PersistentPainTeam@nhs.net Enclsed in this referral pack is a patient infrmatin letter. Please advise the patient that if they are suitable fr ur Service, we will cntact them with an appintment. Yurs faithfully Prtsmuth Persistent Pain Service
Patient Name NHS N Persistent Pain Service Referral Prfrma Referring GP Name DOB Patient aged 18 and ver? Patient s address GP Practice Preferred cntact number Date f referral: Diagnses: Please cnfirm that the patient meets the fllwing inclusin criteria: The patient has a diagnsis f Chrnic Pain The patient is nt seeking further medical interventin r treatment fr their pain There are n nging investigatins/treatments assciated with the patient s cnditin The patient is willing and able t engage in an English speaking grup based prgramme The patient s pain medicatin has been ptimised accrding t the Medicines Management & Drug Frmulary accessed at http://nww.pip.prtsmuthccg.nhs.uk Reasn fr referral: Medical Histry: Clinical Summary f full medical histry and medicatin histry attached Please attach any crrespndence frm the fllwing departments: Pain Clinic Rheumatlgy Orthpaedics Neurlgy Cardilgy Respiratry Any ther lng term cnditins Psychlgical/Psychiatric Histry: Is the patient currently r previusly been under the care f Adult Mental Health (AMH) Services r Child & Adlescent Mental Health Services (CAMHS)? Please attach relevant crrespndence frm: Psychiatry Psychlgy AMH/CAMHS Des this patient present with any current risk? Yes If yes, please give details. N Is transprt required? Yes N Is an interpreter required? Yes N Please specify language Please give yur patient the infrmatin letter and fax the referral and cmpleted questinnaires t: Persistent Pain Service n 23 9268 21.
Patient infrmatin letter: Persistent Pain Service Lng Term Cnditins Suite Grund Flr; Blck A St Mary s Cmmunity Health Campus Miltn Rad Prtsmuth Hampshire PO3 6AD Tel: 23 9268 485 Fax: 23 9268 21 Dear Sir/Madam Yu have been referred by yur GP t the Persistent Pain Service. The Service prvides peple suffering frm persistent pain with grup-based educatin abut chrnic pain. The grups that we run will prvide yu with physical and psychlgical techniques t help self-manage yur cnditin. All f the techniques are based n the latest evidence fr treating persistent pain. Please cmplete the enclsed questinnaires and return them t yur GP, wh will make the referral. The questinnaires help us t identify hw yur cnditin is affecting yu and whether yu are suitable fr the grup sessins. Once yur GP has made the referral t us and if yu are suitable fr ur Service, we will cntact yu t invite yu t an appintment t see ne f ur clinicians. Fllwing this appintment yu will be given the pprtunity t attend a pain Educatin Sessin, designed t help yu with yur chrnic pain. If after attending the pain Educatin Sessin yu decide ur Service is nt suitable fr yu, we will discharge yu back t yur GP. We lk frward t meeting yu. Yurs faithfully Persistent Pain Service
Fr ffice use nly State time pint in service pathway: Prtsmuth Persistent Pain Service Patient assessment questinnaires Name: Date f birth: Date: Brief Pain Inventry (Shrt Frm) 1. Thrughut ur lives, mst f us have had pain frm time t time (such as minr headaches, sprains, and tthaches). Have yu had pain ther than these everyday kinds f pain tday? 1. Yes 2. N 2. Please rate yur pain by circling the ne number that best describes yur pain at its wrse in the last week. N Pain Pain as bad as yu can imagine 3. Please rate yur pain by circling the ne number that best describes yur pain at its least in the last week. N Pain Pain as bad as yu can imagine 4. Please rate yur pain by circling the ne number that best describes yur pain n average in the last week. N Pain Pain as bad as yu can imagine 5. Please rate yur pain by circling the ne number that tells hw much pain yu have right nw N Pain Pain as bad as yu can imagine 6. If this is yur first visit t the clinic g t Questin 7. Hw much relief have pain treatments r medicatins frm this clinic prvided? Please circle the ne percentage that mst shws this. % N pain 1% 2% 3% 4% 5% 6% 7% 8% 9% 1% Cmplete relief
Fr ffice use nly State time pint in service pathway: 7. Circle the ne number that bests describes hw, during the past week, pain has d with yur: A. General Activity Des nt B. Md Des nt C. Walking Ability Des nt D. Nrmal Wrk (includes bth wrk utside the hme and husewrk) Des nt E. Relatinships with ther peple Des nt F. Sleep Des nt G. Enjyment f life Des nt
Fr ffice use nly State time pint in service pathway: GAD-7 Anxiety Over the last 2 weeks, hw ften have yu been bthered by the fllwing prblems? (Please circle the relevant number t answer) Nt at all Several days Mre than Nearly half the every day days 1. Feeling nervus, anxius r n edge 1 2 3 2. Nt being able t stp r cntrl wrrying 1 2 3 3. Wrrying t much abut different things 1 2 3 4. Truble relaxing 1 2 3 5. Being s restless that it is hard t sit still 1 2 3 6. Becming easily annyed r irritable 1 2 3 7. Feeling afraid as if smething awful might happen 1 2 3 Clumn ttals: + + + = Ttal Scre If yu checked ff any prblems, hw difficult have these prblems made it fr yu t d yur wrk, take care f things at hme, r get alng with ther peple? Nt difficult at all Smewhat difficult Very difficult Extremely difficult
Fr ffice use nly State time pint in service pathway: PHQ-9 Depressin Over the last 2 weeks, hw ften have yu been bthered by any f the fllwing prblems? (Please circle the relevant number t answer) Nt at all Several days Mre than half the days Nearly every day 1. Little interest r pleasure in ding things... 1 2 3 2. Feeling dwn, depressed, r hpeless... 1 2 3 3. Truble falling r staying asleep, r sleeping t much....... 1 2 3 4. Feeling tired r having little energy...... 1 2 3 5. Pr appetite r vereating.... 1 2 3 6. Feeling bad abut yurself r that yu are a failure r have let yurself r yur family dwn. 7. Truble cncentrating n things, such as reading the newspaper r watching televisin... 8. Mving r speaking s slwly that ther peple culd have nticed? Or the ppsite being s fidgety r restless that yu have been mving.arund a lt mre than usual..... 9. Thughts that yu wuld be better ff dead r f hurting yurself in sme way... 1 2 3 1 2 3 1 2 3 1 2 3 Clumn ttals + + + = Ttal Scre
Fr ffice use nly State time pint in service pathway: PSEQ PLEASE READ: This survey asks fr yur views abut hw yur pain affects yur cnfidence in achieving everyday activities. Please rate hw cnfident yu are that yu can d the fllwing things at present, despite the pain. T answer circle ne f the numbers n the scale under each item; e.g. = nt at all cnfident and 6 = cmpletely cnfident. Please nte: this questinnaire is nt asking yu whether r nt yu have been ding these things, but rather, hw cnfident yu are that yu can d them at present, despite the pain. 1. I can still enjy things, despite the pain. Nt at all cnfident 1 2 3 4 5 6 cnfident 2. I can still d mst f the husehld chres (e.g. tidying up, washing dishes etc) despite the pain. Nt at all cnfident 1 2 3 4 5 6 cnfident 3. I can scialise with my friends r family members as ften as I used t, despite the pain. Nt at all cnfident 1 2 3 4 5 6 cnfident 4. I can cpe with my pain in mst situatins. Nt at all cnfident 1 2 3 4 5 6 cnfident 5. I can d sme srt f wrk, despite the pain ( wrk includes husewrk, paid r unpaid wrk). Nt at all cnfident 1 2 3 4 5 6 cnfident 6. I can still d many f the things I enjy ding, such as hbbies r leisure activities, despite the pain. Nt at all cnfident 1 2 3 4 5 6 cnfident 7. I can cpe with my pain withut medicatin. Nt at all cnfident 1 2 3 4 5 6 8. I can still accmplish mst f my gals in life, despite the pain. Nt at all cnfident 1 2 3 4 5 6 9. I can still live a nrmal lifestyle, despite the pain. Nt at all cnfident 1 2 3 4 5 6 1. I can gradually becme mre active, despite the pain. Nt at all cnfident 1 2 3 4 5 6 cnfident cnfident cnfident cnfident Ttal: /6