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Covid 19 Information

Please visit www.ghc.nhs.uk/coronavirus/

Self Referral into MSK Physiotherapy Service

IMPORTANT NOTICE

Due to Covid-19 we are currently offering telephone consultations as a first appointment. Additional appointments may be via telephone, video or face to face based on clinical need. For information on how you can help yourself, please visit our webpage.

If you have any urgent health concerns, please use www.nhs.uk for advice.

Thank you for your support and understanding and for helping us to reduce pressures on the NHS.

Prior to completing this self-referral form please be advised that: • We can only accept self-referrals from patients 16 years or older • Referrals are for one condition only, you cannot refer for multiple conditions at a time In some instances the physiotherapist that you are seen by may contact your GP practice to ask for relevant information about your medical history. If you do not want your GP practice to be contacted in this way please make this very clear to the person you see at your appointment.

Patient Details

Title *

First Name *

Last Name *

Date of Birth *

Ethnicity *

Occupation

Address Line 1 *

Address Line 2

Address Line 3

Postcode *

GP Surgery *

Patients must be registered with a Gloucestershire GP

GP's Name *

Who prompted you to complete this electronic self-referral? *

Self

Other Health Professional

Do you require an interpreter?

Yes

Which language?

Who prompted you to complete this referral?

Yourself

GP/Healthcare professional

Are you pregnant?

Yes

Not applicable

Patient Contact Details

Mobile Phone

Home Phone

Work Phone

Email *

Preferred Method of Contact *

Mobile Phone

Home Phone

Work Phone

Please note that the Adult Physio Team cannot arrange appointments via email

Presenting Problem Details

Brief description of the problem you are referring yourself to Physiotherapy for and the body part affected. *

How long have you had the problem for? *

1 week

less than 6 weeks

more than 6 weeks

more than 3 months

Is the problem getting? *

Better

Worse

Staying the same

Are you currently absent from work because of this problem? *

Yes

Not Applicable

Does it wake you from your sleep *

Yes

Sometimes

Availability for work

Working

Unemployed

Not Applicable

Are you the main carer for a family member?

Yes

Is your caring role currently affected by your symptoms?

Yes

At which hospital site would you like your appointment?

Have you attended physiotherapy for this condition before? *

Less than 1 year

More than 1 year

Is this referral for back pain and/or sciatica? *

Yes

Thinking about the last 2 weeks tick your response to the following questions:

1. My back pain has spread down my leg(s) at some time in the last 2 weeks

Disagree

Agree

2. I have had pain in the shoulder or neck at some time in the last 2 weeks

Disagree

Agree

3. I have only walked short distances because of my back pain

Disagree

Agree

4. In the last 2 weeks, I have dressed more slowly than usual because of the back pain

Disagree

Agree

5. It’s not really safe for a person with a condition like mine to be physically active

Disagree

Agree

6. Worrying thoughts have been going through my mind a lot of the time

Disagree

Agree

7. I feel that my back pain is terrible and it’s is never going to get any better

Disagree

Agree

8. In general I have not enjoyed all the things I used to enjoy

Disagree

Agree

9. Overall, how bothersome has your back pain been in the last 2 weeks?

Gloucestershire Health and Care NHS Foundation Trust Staff Only

Are you an employee of Gloucestershire Health and Care NHS FT?

Yes

Where is your place of work?

What is your occupation?

Are you currently absent from work as a result of this problem?

Yes

Line managers may request to know about appointment times and attendance which fall within your contracted work hours. Whilst they are entitled to this information, no details of your clinical condition or treatment will be disclosed without your prior permission.

Covid 19 Information

Self Referral into MSK Physiotherapy Service

Patient Details

Patient Contact Details

Presenting Problem Details

Thinking about the last 2 weeks tick your response to the following questions:

***Gloucestershire Health and Care NHS Foundation Trust Staff Only***

Gloucestershire Health and Care NHS Foundation Trust Staff Only