Physiotherapy Self Referral

Physiotherapy Self Referral
DISCLAIMER

Please note that we are using Jotform as part of our referral process. Further information can be found on our website. https://www.hrch.nhs.uk/download_file/view/842/377

Physiotherapy Self Referral
Please Read This Before Continuing

Please consult your GP or NHS 111 urgently if you have recently or suddenly developed:

• New pain, pins and needles or numbness travelling down both legs
• New weakness in your legs – this may cause you to stumble or trip, or not be sure where your feet are landing
• Numbness or tingling around your inner thighs, genitals, back passage or buttocks
• Any new changes to how your bladder and bowels work e.g. difficulty weeing/starting the flow, weeing more often, not knowing when you need to go to the toilet, weeing or pooing yourself, etc.
• New changes for men in their ability to achieve an erection or ejaculate or loss of sensation during sexual intercourse
• New changes for women in their ability to fully feel sensation in the genital or vagina area or climax during sexual intercourse

Please discuss with your GP before submitting this referral if you:

• Have severe pain at night which keeps you awake for hours or stops you from being able to lie flat
• Have experienced unexplained weight loss
• Are feeling generally unwell in yourself
• Have a Fever
• Have or have had tuberculosis (TB) or a urinary tract infection (UTI – infection of your water works)
• Have a HIV infection
• Have a past history of cancer – breast, lung, bowel, prostate, kidney and thyroid
• Have recently become unsteady on your feet
• Have experienced night sweats

If you have any difficulties with this form please call us on 0208 714 4019

Physiotherapy Self-referral

Your name and contact details
Full Name*

First NameLast Name
Gender*

MaleFemalePrefer not to sayOther
Date of Birth*

DayMonthYear
Date
Email Address (if applicable)

Confirmation Emailexample@example.com
Address

Street Address

Street Address Line 2

City

Post Code
Contact Telephone Number (preferred contact phone number)*

Further Information
NHS Number*
Registered GP*
Are you able to attend an Outpatient Clinic?
Do you need an interpreter?
Language
Ethnicity
If other, please specify
Occupation
Off work due to this problem?
If you are currently off work due to this problem, how long have you been off work for?
Are you a registered carer?
Are you having difficulty caring for someone due to this problem?

Your symptoms
Describe fully your symptoms/ pain/ problem, (include odd sensations)*
Do you have any areas of skin that you are unable to feel when you touch yourself?
When and how did your symptoms start? (e.g 1 week ago lifting)*

About Your Symptoms
Are your symptoms:
If Other, please specify
Are your symptoms present:
If other, Please specify
Do you find the symptom disturbs your sleep:
If other, please specify
Are your symptoms:
If other, please specify

What Affects Your Symptoms
Please describe anything you have found that makes your symptoms worse
Please describe anything you have found that makes your symptoms easier
Please tell us if you have had any previous treatment for this problem, e.g. medical treatment, GP, Physiotherapy, Osteopathy, Chiropractic
Please tell us if you have had any investigations for this problem such as X-ray, MRI, blood tests, etc (including results)

New Episodes or Changes
Please let us know if you had any new episodes of or changes to

Swelling of a jointPainful clickingGiving-way of your leg or knee resulting in stumbling or fallingLocking of your knee resulting in you being unable to bend or straighten your leg, or having to physically 'unlock' your knee with your handsNone of the above
Please let us know if you have had any new episodes of or changes to? (Please add further appropriate information in the text box below)
Further information about existing medical conditions
Have you tried the GetUBetter App for this problem

Other Information
Please list all your current medications including any painkillers
Please tell us anything else you think maybe relevant to this referral
Should be Empty: