Back Pain Back Pain CLINICIAN- Has warning symptoms please review patient. Patient has indicated they have one of: Thoracic back pain Bilateral Sciatica Possible vertebral crush # Possible Spinal Stenosis History of Cancer CLINICIAN- Patient wishes physio CLINICIAN – Patient wishes medication Please review medication requests. CLINICIAN – Patient wishes reviewPlease review form and decide whether to phone patient or offer F2F Complete this form to tell us about your back pain and we will be in touch. Back pain is very common and usually settles by itself within 6 weeks with painkillers and stretching. Most back pain doesn’t require review by a doctor, a physiotherapist or a scan. It’s usually caused by muscle pain, wear and tear of the joints in the back or a slipped disc (disc prolapse). Helpful information on managing your back pain can be found here. Your details Patient Name * Date of Birth * Mobile number to contact you * Email address if you’d like sent a copy of the completed form Your Symptoms First we must ensure you do not have symptoms of cauda equina: Numbness / pins and needles between your inner thighs, genitals or back passage Increasing difficulty when you try to urinate loss of sensation when you pass urine leaking urine or bowels not knowing when your bladder is either full or empty If you develop back pain along with any of these symptoms please immediately phone 111 or attend Accident and Emergency. I confirm I have no symptoms of Cauda Equina. * I will phone 111 if I develop these symptoms Tell us briefly how your back pain started. * What kind of back pain do you have? * This is new back pain (Acute back pain) This is a sudden worsening of my usual back pain (Acute on Chronic Back pain) I have had back pain for a long time (Chronic Back pain) How long have you had this episode of back pain? * LESS than 6 weeks MORE than 6 weeks Where is your back pain? (Please see picture) * Thoracic (Upper middle) Lumbar (Lower) Sacrum (Bottom) Sciatica Wear and tear in your back can cause nerves to be trapped causing pain, tingling or numbness down one leg past the knee (sciatica). Sometimes nerve (neuropathic) painkillers are required to control the pain. Sciatica usually settles by itself. If it lasts longer than 6 weeks then physiotherapy is recommended. Do you have Sciatica? * No Yes, down my LEFT leg Yes, down my RIGHT leg Yes, down BOTH legs Do you have any of the following? * I have a history of cancer My back pain started after a fall Standing for for short periods makes my pain worse and quickly goes when sitting I am over 60 years old and my back pain came on suddenly when I sat down None Treatment Options Stretching Exercises Back pain can be treated effectively at home with stretching exercises. Stretching helps relax muscle spasm, reduce the stiffness of worn joints and help release trapped (squashed) nerves. You can do these exercises at home without needing a physiotherapist. Stretching * I have considered the above advice on stretching exercises. Your back pain has been present for more than 6 weeks. Would you like some NHS Physiotherapy? They can also refer you for a scan if they think appropriate. No thank you Yes please, I will get in touch with the NHS physio service here Painkillers for Back Pain Back pain can usually be managed with painkillers from the supermarket or pharmacy. A combination of paracetamol and ibuprofen is usually all that is needed. Co-codamol 8/500 mg (Codeine / Paracetamol) tablets is stronger than paracetamol alone and can be obtained from the pharmacy without a prescription. It can be taken with ibuprofen. How is your pain? * I am managing with my current painkillers I would like stronger prescription painkillers Prescription Painkillers Stronger Anti-Inflammatories such as Naproxen or Diclofenac instead of Ibuprofen. These are not addictive but can affect your stomach or kidneys if taken long-term. Strong Opiates such as Co-codamol 30 / 500 or Tramadol. These are addictive and should only be taken short-term. Which painkillers would you like to try? (If thought appropriate by the Doctor reviewing your notes) * I would like a prescription for a for a stronger Anti-inflammatory painkiller eg Diclofenac I would like a prescription for a for a stronger Opiate painkiller eg Co-Codamol I would like a prescription for a for a stronger Anti-inflammatory and Opiate painkiller Painkillers for Sciatica Sciatica pain often isn’t treated well with normal painkillers and often requires special painkillers which help with nerve problems. Amitriptyline – this painkiller is taken in the evening and helps not only with the pain but is a mild sedative and so helps with sleep. It is not addictive. Gabapentin – This painkiller is considered stronger than amitriptyline for nerve pain but doesn’t help with sleep. It is taken three times daily. It can be addictive in a small number of people who take it. Pregabalin – This painkiller works in a similar way to Gabapentin. It is often used when a patient finds Gabapentin isn’t effective or has intolerable side effects. Medication for Sciatica pain * I would not like any medication for sciatica I would like STARTED on Amitriptyline for my Sciatica I would like to be STARTED on Gabapentin for my Sciatica I am already taking a medication for sciatica and I would like a DOSE INCREASE I am taking Gabapentin but I would like to try PREGABALIN instead How would you like to proceed? I am happy with this form being reviewed and actioned by a clinician as appropriate I would like to SPEAK TO A CLINICIAN This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our privacy policy to discover how we protect and manage your submitted data. 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