Royal Melbourne Hospital Spinal Referral Form
Fax: 9342 4234	
Patient Details:	
Name: <<Patient Demographics:Full Name>>	Date of Birth: <<Patient Demographics:DOB>>	RMH UR (if known): <<RMH UR (if known)>>	
Address:  <<Patient Demographics:Address Preferred Line 1>>, <<Patient Demographics:Address Preferred Line 2>> <<Patient Demographics:Address Preferred City>>   <<Patient Demographics:Address Preferred Postcode>>	o TAC	o WorkCover: Number: <<WorkCover Number>>	
Phone: <<Patient Demographics:Phone (Home)>>	If interpreter required (specify language): <<If interpreter required (specify language)>>	
Referrer Details:	
Name: <<Doctor:Name>>	Phone: <<Doctor:Phone>>	
Practice Address:	<<Practice:Address>>	
Referral Details:	
Reason for referral (include affected areas and symptom duration):
<<Reason for referral (aff. areas, symptom duration)>>

Preferred Service: o Back pain Assessment Clinic (BAC)	o Neurosurgery	o Orthopaedics	o Rheumatology	o Multidiscipliary Pain Service	
Please tick all relevant boxes	
Q.1. Any referred/ neurological symptoms?	Upper Limb

	Right	Left	Lower Limb

	Right	Left	Additional Informaton	
o Yes §§§§§§§§§§è	Referred pain	o	o		o	o		
o No 	Next Question	Limb Weakness	o	o		o	o		
	Abnormal sensation	o	o		o	o		
	Abnormal reflex	o	o		o	o		
	Abnormal tone	o	o		o	o		
	
Q.2. 
Urgent (red flag)
symptoms:
o Yes §§§§§§§§§§è	o History of cancer. Details (site/date diagnosed)
o Severe unremitting pain with nocturnal pain causing sleep disturbance
o Suspected ankylosing spondylitis/spinal inflammation	
o No 	Next Question	Suspected cauda equina syndrome, spinal infection, spinal 
malignancy or worsening neurological deficits should be 
immediately referred to the Emergency Department	
	
Q.3. 
Current / Previous Management	o Physiotherapy/chiropractic/osteopathy
o Exercise rehabilitation
o Spinal injection. Details
o Spinal surgery. Details
o Analgesia	
		o NSAIDs	o Weak Opioids
	o TCA e.g. amitriptyline	o Strong Opioids
	o Pregabalin/Gabapentin	o Other	
	
Q.4. 
Current / Previous Investigations	o X-ray (minimum requirement)
o CT scan
o MRI scan
o Bone scan
o Relevant blood tests	
Please attach formal reports
(Referrals without a imaging report attached will not be triaged)

(e.g. CRP, ESR, HLA-B27)	
	
Q.5. General Health / Social History:	Please complete or attach current medical history and medication list	

	

			

For advice on the assessment and management of back pain and sciatica, please refer to the Low Back Pain in Adults Pathway at https://melbourne.healthpathways.org.au

The pathway covers:
•	Assessment - includes recognising red flags and yellow flags
•	Management - patient education, self-management strategies, guidance on non-pharmacological and pharmacological options for pain relief, when and where to refer patients for specialist care
•	Links to useful clinical resources and patient information