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Home Our Services Allied Health Professions Musculoskeletal Physiotherapy Outpatients Service Musculoskeletal Physiotherapy Self Referral Form

Musculoskeletal Physiotherapy Self Referral Form

PLEASE NOTE: THIS REFERRAL FORM IS FOR SOUTHERN TRUST CLIENTS ONLY.
THANK YOU

We are aware some patients are unable to submit the referral online, if this affects you please fill out the paper version and send it to the address on the paper copy. You may print out the paper referral off the website, or pick up a copy from your GP or local physiotherapy department

Name*
Please enter your title, first name and surname
Title: Mr/Mrs/Ms/Miss etc First Last
Today's Date*
DD slash MM slash YYYY
Date of Birth*
Your Health and Care Number (if known)
Your Address*
Please enter your home address

Street Address Town/City County Postcode
Your GP's name
Please select the name of the GP you are registered with from the list below. If you can't find your GP listed fill in the next question.
GP - other ?
Please enter the name of the GP you are registered with, if they are not on the list above.
GP Practice Address*
Street Address Town/City County Postcode
Did your GP suggest self-referral to Physiotherapy ?*
- Yes
- No
Contact Details

Please enter telephone numbers that you are happy to be contacted at if more information is required. If we ring you, it may display unknown number on your phone. Please be aware of this.
Home
Work
Mobile
Your Email Address
Please enter your email address if you have access to an email account and wish to receive confirmation of your request.
Do you require an interpreter ?*
- No
- Yes
If Yes, which language?
Do you require adjustment for reasons related to a disability?*
- No
- Yes
If so give details
Where is your main problem? Please only select ONE*
- Back
- Neck
- Shoulder
- Arm
- Elbow
- Wrist
- Hand
- Chest
- Hip
- Knee
- Leg
- Foot
How long have you had this problem?*
- 0 - 6 weeks
- 7 - 12 weeks
- > 13 weeks
- > 1 year
Have you seen your GP or anyone else in your GP practice about this problem?*
- Yes
- No
Is the problem new?*
- New
- Return of an old problem
Are the symptoms getting worse?*
- Yes
- No
In what way are symptoms getting worse?
Are you able to carry out your normal activities, work, care for a dependant, sport at present?*
- Yes
- No
Please give details*
What are you having difficulty with?
Do you know what caused your problem?*
- Yes
- No
If Yes please give details*
Do you have any other medical condition or information that you think may be relevant e.g. Cancer, previous fractures, Diabetes, Osteoporosis?
Please give some details
Sometimes we miss what is most important to you, what is concerning you most?*
Have you lost weight in the past 6 months for reasons you cannot explain?*
- Yes
- No
If Yes how much?*
Have you developed Numbness / Tingling / Pins and Needles since the start of your problem?*
- Yes
- No
If YES, where ?*
Since the onset of your problem, do you have any of the following symptoms?*
Please tick any that apply.
- A new episode or a sudden change to your ability to control or to pass urine?
- A new loss of sensation to your inner thighs, genitals or back passage area?
- A new difficulty with Bowel function resulting in a loss of bowel control (soiling yourself)
- None of the above
If you answered YES to any of the questions above and you HAVE NOT seen a doctor for your symptoms, it is essential that you arrange for URGENT advice from your GP or attend your local Emergency Department

DO NOT SEND IN THIS FORM UNTIL YOU HAVE SOUGHT FURTHER ADVICE
By submitting this form you confirm that the information you have provided is accurate.
Phone
This field is for validation purposes and should be left unchanged.

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Southern Health and Social Care Trust

Southern College of Nursing, Craigavon Area Hospital, 68 Lurgan Road, Portadown, BT63 5QQ

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028 3833 4444

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028 3083 5000

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028 8772 2821

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028 3832 3262

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028 3752 2381

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