DVA Referral Form

DVA Referral Form Date: 1 November 2024 Patient Details: Name: John Smith Date of Birth: 15/03/1960 DVA File Number: C1234567J Address: 123 ANZAC Avenue, Veteranville, VIC 3000 Contact Number: 0412 345 678 Referring Doctor Details: Name: Dr. Eleanor Vance Provider Number: 234567XA Clinic Name: Bayside Medical Centre Clinic Address: 456 Marina Parade, Bayside, VIC 3207 Contact Number: (03) 9876 5432 Reason for Referral: Chronic lower back pain exacerbated by prolonged standing and lifting, impacting daily activities and quality of life. Patient has a history of military service with heavy lifting duties. Services Required: Pain Management Specialist Consultation and ongoing physiotherapy for chronic lower back pain. Past Medical History Relevant to Referral: Osteoarthritis of lumbar spine, previously managed with NSAIDs and occasional chiropractic care. History of L5/S1 disc bulge in 2010, no surgical intervention. No red flag symptoms (e.g., cauda equina syndrome, progressive neurological deficit). Current Medications: Paracetamol 500mg, 2 tablets as needed for pain (max 8/day) Ibuprofen 400mg, 1 tablet three times a day with food Allergies: Penicillin (rash) Investigation Results (Attach relevant reports): Lumbar spine X-ray (October 2023): Degenerative changes at L4/L5 and L5/S1, mild disc space narrowing. Lumbar MRI (June 2024): Confirmed degenerative changes, no significant nerve root compression. Provisional Diagnosis: Chronic non-specific lower back pain secondary to degenerative disc disease and osteoarthritis, likely exacerbated by occupational history. Anticipated Duration of Treatment: Ongoing as per specialist recommendation, likely several months of intensive physiotherapy followed by maintenance program. Declaration: I certify that the above information is true and correct and that this referral is clinically appropriate for the care of the above-named patient. Signature of Referring Doctor: Dr. Eleanor Vance (electronically signed) Recipient of Referral: Dr. Marcus Thorne (Pain Management Specialist) Optimal Health Clinic 789 Medical Drive, Metroville, VIC 3000 Fax: (03) 1234 5678 Additional Notes for Recipient: Patient experiences significant functional limitations. Please assess for suitability for targeted injections or other interventional pain management strategies. Patient is keen to explore non-pharmacological options.