Physiotherapy self-referral

Your name and contact details

First Name

Last Name

Gender

Date of Birth

Email address

Postcode

Address

Contact Telephone Number
(preferred contact phone number)

Further Information

NHS Number (if known)

Registered GP Surgery

Are you able to attend an Outpatient Clinic?

Do you need an interpreter?

Language

Ethnicity

Occupation

Off work due to this problem?

Are you a registered carer?

Are you having difficulty caring 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

Are your symptoms present

Do you find the symptom disturbs your sleep

Are Your symptoms

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)

Your Back Pain

If you have a back problem please fill in questions below (Thinking about the last 2 weeks). If you do not have back pain go to the next section (Existing Medical Conditions)

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

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

I have only walked short distances because of my back pain

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

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

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

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

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

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

New Episodes Or Changes

Please let us know if you have had any new episodes of or changes to

Swelling of a joint

New locking or giving way of your knee

None 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

Other Information

Please list all your current medications including any painkillers

Please tell us anything else you think maybe relevant to this referral

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