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*
GP's Name*
Who prompted you to complete this electronic self-referral?*
- Self
- GP
- Other Health Professional
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
- No
- Not Applicable
Does it wake you from your sleep*
- Yes
- No
- Sometimes
Availability for work
- Working
- Unemployed
- Not Applicable
At which hospital site would you like your appointment?
- Cheltenham General Hospital
- Gloucestershire Royal Hospital
- North Cotswolds Hospital - Moreton
- George Moore Community Clinic - Bourton
- Tewkesbury Community Hospital
- Winchcombe Clinic
- Fairford Hospital
- Vale Community Hospital
- Dilke Memorial Hospital
- Lydney District Hospital
- Stroud General Hospital
- Cirencester Hospital
Have you attended physiotherapy for this condition before?*
- Less than 1 year
- More than 1 year
- No
Is this referral for back pain?*
- Yes
- No
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?
- Not at all
- Slightly
- Moderately
- Very much
- Extremely
***Gloucestershire Health and Care NHS Foundation Trust Staff Only***
Are you an employee of Gloucestershire Health and Care NHS FT?
- Yes
- No
Where is your place of work?
What is your occupation?
Are you currently absent from work as a result of this problem?
- Yes
- No
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