Self-Referral for Routine Adult Out-Patient Physiotherapy (over 16 years of age)

IMPORTANT - This form must be completed in full or an appointment may be delayed

Name: Mr/Mrs/Miss/Ms Address:

Date of Birth:

Date of Referral: Postcode: Hospital Number (if known): GP (Name and Address):

NHS Number (if known):

Tel No: Home Work Mobile No

Do you require an Interpreter? YES / NO If yes, which language?

What current symptom do you have requiring Physiotherapy?

Early advice If you feel your condition just requires some advice; a Physiotherapist will call you and discuss the most appropriate way to manage your problem. ADVICE Yes

Is the problem New? Ongoing

How long have you had this problem? (please state number) ……..Weeks …... Months …... Years

Have you had any previous treatment for this problem? YES / NO When?

Are the symptoms worsening? N/A N/A Are you off work/unable to care for a dependent because of this problem? N/A

If you have night pain- If yes, please describe

Have you suddenly lost weight without trying?

Have you developed new problems with your bladder or bowel since the onset of your back/leg pain? Yes  No  Can you mark on the body chart where you are getting the pain / problem?

Have you had any other symptoms such as tingling/numbness/muscle weakness? Please mark on body chart above.

Using a scale of 0 to 10, score your average level of pain, where 0 is no pain and 10 is the worst possible pain 0 1 2 3 4 5 6 7 8 9 10  

Please list any medication you are taking and how many painkillers a day?

Please tell us of any other relevant medical history:

Signature ______Date ______

How can I submit this form? Please return this form by email to [email protected] or post to: AHP Central Appointments, Merrington House, Merrington Lane Industrial Estate, , DL16 7UT

Patients in the North Durham area will be given the choice to attend hub clinics at either: University Hospital of North Durham, Chester-le-St Hospital, Shotley Bridge Hospital, Stanley Primary Care Centre, Health Centre or Belmont & Sherburn Medical Group

Patients in the South Durham area can choose to be seen at any of the venues and are also welcome to post the form direct to their chosen venue for treatment;

Physiotherapy Dept, Memorial Hospital, Hollyhurst Road, Darlington, DL3 6HX Physiotherapy Dept, General Hospital, Cockton Hill Road, Bishop Auckland, DL14 6AD Physiotherapy Dept, Community Hospital, Salters Lane, Sedgefield, TS21 3EE Physiotherapy Dept, Richardson Hospital, Victoria Road, , DL12 8ET