ChamplainMSKcare - Home



Musculoskeletal Program – Spine*This referral is not to be used for urgent referrals.* Cornwall Community Hospital - H?pital Montfort- Queensway Carleton HospitalThe Ottawa Hospital - Pembroke Regional HospitalRequest For ConsultationFax: 613-721-7889REFERRAL DATE (YYYY/MM/DD):Referring Physician Information – may use stampName:________________________________________Specialty: ________________________________________Address: ________________________________________________________________________________Phone: ________________________________________Fax: ________________________________________Billing #: ________________________________________Signature: ________________________________________Family Physician Information (if different)Name: ________________________________________Phone:________________________________________Fax: ________________________________________Patient Information – may use stickerName:________________________________________Address:________________________________________________________________________________________________________________________Phone:________________________________________Date of Birth: ________________________________________Health Card #: ________________________________________Gender:? Male ? FemaleAlternate Contact Information:________________________________________________________________________________________________________________________Spinal Level:? Cervical ? Thoracic ? Lumbar-SacralPain Dominance:(for severity of pain, use 0-10 scale, 10 = worst imaginable) ? Back/Neck Severity of Back Pain: ___________________Severity of Neck Pain: ___________________? LegSeverity of Leg Pain: ____________________? ArmSeverity of Arm Pain: ___________________Specify Dermatome: _______________________Specify Laterality: ? Left ? Right ? BilateralDuration of Symptoms:? <6 Weeks? 6-12 Weeks? 3-6 Months? 6-12 Months? >12 MonthsObjective Neurological Loss (select all that apply):? Motor? Sensory? Bowel/Bladder? Upper Motor Neuron Signs? Other Specify: ________________________________Is patient’s pain / disability significant enough that they would like to undergo surgery?? Yes? No? MaybeDiagnosis:? Back Pain? Neck Pain? Radiculopathy / Sciatica? Myelopathy? Neurogenic Claudication? Deformity / Scoliosis / Kyphosis? Other Specify: _________________________________Pathology:? Disc Herniation? Degenerative Disc Disease /Facet Arthropathy? Spinal Stenosis? Spondylolisthesis? Deformity / Scoliosis / Kyphosis? Fracture – Traumatic? Fracture – Pathological? Tumour? Intradural? Inflammation? Infection? Other Specify: ________________________________Treatment to Date:? None? Physiotherapy Length of Time: __ ____________________ Benefits Received: ________________________ ________________________________? Cortisone Injection(s) Response to Injection: ? None ? Partial ? Complete? Exercise Program(s) Length of Time: _ _____________________ Benefits Received: ____________________ ___ _ _____________________________? Other Specify: ________________________________Surgeon Preference:? First Available Surgeon? Specific Surgeon: ______________________________________Diagnostic Imaging:Attach minimum 1 MRI Report (within the last 1 year)? MRI report has been attachedIf unable to get MRI, please specify reason: ____________ _______________________________________ ___________________________If unable to get MRI, please attach one of the following reports:? CT ? CT myelogram ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download