Self Referral Form Adult Musculoskeletal Physiotherapy

U R Medway Only Clinicians:- Band TI 5 6 7 Triage:LBP/Non LBP Non triage FR OR LTC LX TX CX LL UL Initial Self Referral Form – Adult Musculoskeletal Physiotherapy PhysioPhysiotherapyFor Official Use Only

Patient Details: GP Details: Title: Mr/Mrs/Ms/Miss Name: First Name: GP Practice Address: Surname:

Address:

Information: Postcode: Do you require an interpreter? Yes/No Contact Tel. No: (Home) (Work) If yes, which language? (Mobile) NHS Number if known: Can we leave a message on any of these numbers? Date of referral: Occupation:

Date of Birth:

Please give a brief description as to why you would like a Physiotherapy assessment:

On the chart below please indicate the area where you feel your problem is; please indicate any areas of pain, pins and needles or numbness.

Front Back Right Left

Pins & Needles

Circle area for numbness

If you have back pain with leg pain have you had any difficulties passing or controlling urine? Yes/No

Have you suddenly lost weight without trying? Yes / No Page 1 If any of the following is relevant to your pain please speak to your GP first.

 Trauma i.e. fall from height, road accident  Constant increasing pain  Previous cancer history  Drug usage – HIV  Sudden unplanned weight loss  Steroid use  Generally unwell  Difficulties with urine/bowel problems

Please list any medication you are taking or attach copy of medication list

Symptom History: Please tick as appropriate.

When did this problem start? Less than 2 weeks / 2-8 weeks / 8-12 weeks / more than 12 weeks?

Is the problem:

New □ Ongoing □ Flare up of an old problem □

Getting better □ Getting worse □ Staying the same □

Does it wake you at night? Yes □ No □

Are you off work/unable to care for a dependent Yes □ No □ because of this problem?

Is the problem stopping you from doing things? Yes □ No □

Please specify:

If you have pain, please indicate how severe your pain is on this scale of 0 - 10

0 1 2 3 4 5 6 7 8 9 10

No pain at all Mild Moderate Severe Worst pain possible Page 2 Medical History - Please tick as appropriate.

Have you consulted your GP about this problem? Yes □ No □

Have you tried anything to help with your problem? Yes □ No □ (e.g. pain killers, exercise, other treatment)

Please specify:

Have you had Physiotherapy for the same problem in the last 6 months? Yes □ No □

If so, where did you have your Physiotherapy?

Are you suffering from any of the following:

MRSA □ C.diff □ diarrhoea & vomiting □ scabies □

Impetigo □ undiagnosed skin rash □

IMPORTANT. Adult Physiotherapy is for patients aged 16 and above, patients with problems affecting muscle joints etc, including back pain, neck pain and shoulder pain.

Take , send or fax your completed referral to the Physiotherapy Department at: Adult Musculoskeletal Physiotherapy Department Medway Maritime Hospital Windmill Road Gillingham Kent ME7 5NY

Contact Tel: 01634 833959 Fax: 01634 402877 Email: [email protected]

A physiotherapist will look at your form and prioritise based on the information you have supplied. We will contact you regarding an appointment in due course.