Self-Referral-Physio-Ben-And-Ghh.Pdf
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Self-Referral Referral Form Please complete this form & return to your preferred clinic (see clinic list overleaf) or contact 0121 465 2386 or 0121 424 9053 to make a physiotherapy appointment: Full Name: …………………………………. Date of Birth: ……. / ……. / ……. Gender (please circle): Male / Female Address: ……………………………………. Registered GP: ………………………………. ………………………………………………… GP Address: …………………………………. Postcode: …………………………………... …………………………………………………. Tel (day) …………………………………. Preferred language: …………………………. □ Do you require an interpreter: Yes / No (mob)………………………………….□ Please list any current medication: (work)………………………………….□ …………………………………………………… (Please indicate preferred contact number) …………………………………………………… …………………………………………………… Please give a brief description of why you Please indicate on the body chart where your require a physiotherapy assessment: problem/pain/symptoms occur: ………………………………………………… ………………………………………………… ………………………………………………… ………………………………………………… ………………………………………………… ………………………………………………… Is this problem (please circle): New / Ongoing How long have you had this problem? ………………………………………………… Is this problem getting (please circle): Better / Worse / Staying the same Have you seen your doctor about this problem? Yes / No Have you previously had treatment for this problem? Yes / No Please give details ………………………………………………………………………………... Are you currently off work / unable to care for a dependent due to this complaint? Yes / No If you have back pain or leg pain, have you had any difficulty passing or controlling urine? Yes / No (If ‘Yes’, please give details) ……………………………………………………….. Have you had any sudden unexplained weight loss? Yes / No (If ‘Yes’, please give details) ………………………………………………………………………. Have you had any other symptoms e.g. numbness, tingling, weakness? Yes / No (If ‘Yes’, please give details) ………………………………………………………………………. Clinic Locations Use the list below to choose your closest/preferred clinic. Please deliver your referral form by post or direct to your chosen clinic. If you are unable to complete the form yourself or require assistance to complete the form please contact 0121 465 2386 Swan Centre For Physiotherapy Treaford Lane Clinic 17 Willard road 73 Treaford Lane Yardley Alum Rock Birmingham Birmingham B25 8AB B8 2UE Saltley Health Centre Castle Vale Primary Care Centre Craddock Road Tangmere Drive Saltley Castle Vale Birmingham Birmingham B8 1RZ B35 7QX Sutton Cottage Hospital Walmley Health Centre 27a Birmingham road 8a Walmley Road Sutton Coldfield Sutton Coldfield West Midlands West Midlands B72 1QH B76 1QN Ley Hill Surgery Stockland Green Primary Care Centre 228 Lichfield Road Reservoir road Sutton Coldfield Erdington West Midlands Birmingham B74 2UE B23 6DJ Warren Farm Health Centre The Dove Primary Care Centre Warren Farm Road Dovedale Road Kingstanding Birmingham Birmingham B23 5BB B44 0PU Good Hope Hospital Heartlands Hospital Physiotherapy Department Physiotherapy Department Rectory Road Bordesley Green East Sutton Coldfield Birmingham B75 7RR B9 5SS Solihull Hospital Physiotherapy Department Lode Lane Solihull B91 2JL.