Download MD template - Primary Health Tasmania

Alcohol and Drug Dependency Act 1968 - (Section 22)
CONFIDENTIAL
The Secretary
Department of Community and Health Services
GPO Box 125B
HOBART TAS 7001
Attention: Chief Pharmacist
I, <<Doctor:Name>>
of
<<Practice:Name>>, <<Practice:Address>>
a legally qualified Medical Practitioner, hereby apply for the following drug(s) to be made available for the use of the
patient specified in this application who, in my opinion, <<Dependency>>
Name of Drug(s) <<Name of Drug(s)>>
Full name of Patient: <<Patient Demographics:Full Name>>
Full residential address of Patient: <<Patient Demographics:Full Address>>
D.O.B.: <<Patient Demographics:DOB>> Sex: <<Patient Demographics:Sex>> Marital Status: <<Marital>>
Nationality: <<Nationality>>
Occupation: <<Patient Demographics:Occupation>>
Drug(s) and dose(s) prescribed: <<Drug(s) and Dose(s) prescribed>>
Condition for which drug(s) prescribed: <<Condition Drug(s) prescribed for>>
Classification of Patient:
No degree of dependency
Drug Dependent
Some degree of dependency
Terminal


Origin of extended treatment:
Therapeutic
Other
Unknown
Any additional remarks: (attach clinical reports where applicable)
Additional Information:
Insurance claim:
MAIB
Taxonomy Key
(Please tick boxes on second page)
Template created by General Practice South June 2009
Workplace

CLASSIFICATION OF CHRONIC PAIN TAXONOMY
Pain specialist assessment:
Doctor: <<Pain Specialist name>>
Dated this <<Dated - Day of Month>> day of <<Month of Year>>
Date: <<Pain Assessment Date>>
<<Year>>
Signature
Template produced by General Practice South June 2009. Scale reproduced from ISAP 2nd Edition 1994
CLASSIFICATION OF CHRONIC PAIN TAXONOMY
Place X in relevant boxes
I. Region*
Head, face and mouth
000

Cervical region
100

Upper shoulder & limbs
200

Thoracic region
300

Abdominal region
400

Lower back, lumbar spine, sacrum & coccyx
500

Lower Limbs
600

Pelvic region
700

Anal, perineal & genital area
800

More than three major sites
II. System
Nervous system (central, peripheral and autonomic) and special senses;
physical disturbance or disfunction
900

00

Nervous system (psychological and social)
10

Respiratory & cardiovascular systems
20

Musculoskeletal system & connective tissue
30

Cutaneous & subcutaneous & associated glands (breast, apocrine, etc.)
40

Gastrointestinal system
50

Genito-urinary system
60

Other organs or viscera (e.g. thyroid, lymphatic, hemopoietic)
70

More than one system
80

Unknown
III. Pattern of Occurence
Not recorded, not applicable, or not known
90

0

Single episode, limited duration
1

Continuous or nearly continuous, nonfluctuating
2

Continuous or nearly continuous, fluctuating severity
3

Recurring irregularly
4

Recurring regularly
5

Paroxysmal
6

Sustained with superimposed paroxysms
7

Other combinations
8

None of the above
9

IV. Intensity - Time since onset of current
pr
V.Etiology
0

Genetic or congenital disorders
.00

--1 month or less
.1

Trauma, operation, burns
.01

--1 month to 6
.2

Infective, parasitic
.02

Not recorded, not applicable, or not known
Mild
oblem
months
Template produced by General Practice South June 2009. Scale reproduced from ISAP 2nd Edition 1994
CLASSIFICATION OF CHRONIC PAIN TAXONOMY
--more than 6
.3

.03

--1 month or less
.4

Neoplasm
.04

--1 month to 6
.5

Toxic, metabolic
.05

--more than 6
.6

Degenerative, mechanical
.06

--1 month or less
.7

Disfunctional (including psychophysiological)
.07

--1 month to 6
.8

Unknown or other
.08

--more than 6
.9

Psychological origin
.09

months
Medium
Inflammatory (no known infective agent),
immune reactions
months
months
Severe
months
months
*Region - main site first, second regions, seperately if more than one.
Template produced by General Practice South June 2009. Scale reproduced from ISAP 2nd Edition 1994