<p> 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 </p><p>Patient Details: GP Details: Title: Mr/Mrs/Ms/Miss Name: First Name: GP Practice Address: Surname:</p><p>Address:</p><p>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:</p><p>Date of Birth:</p><p>Please give a brief description as to why you would like a Physiotherapy assessment:</p><p>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.</p><p>Front Back Right Left</p><p>Pain</p><p>Pins & Needles</p><p>Circle area for numbness</p><p>If you have back pain with leg pain have you had any difficulties passing or controlling urine? Yes/No</p><p>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.</p><p> 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</p><p>Please list any medication you are taking or attach copy of medication list</p><p>Symptom History: Please tick as appropriate.</p><p>When did this problem start? Less than 2 weeks / 2-8 weeks / 8-12 weeks / more than 12 weeks?</p><p>Is the problem:</p><p>New □ Ongoing □ Flare up of an old problem □</p><p>Getting better □ Getting worse □ Staying the same □</p><p>Does it wake you at night? Yes □ No □</p><p>Are you off work/unable to care for a dependent Yes □ No □ because of this problem?</p><p>Is the problem stopping you from doing things? Yes □ No □</p><p>Please specify:</p><p>Pain</p><p>If you have pain, please indicate how severe your pain is on this scale of 0 - 10</p><p>0 1 2 3 4 5 6 7 8 9 10</p><p>No pain at all Mild Moderate Severe Worst pain possible Page 2 Medical History - Please tick as appropriate.</p><p>Have you consulted your GP about this problem? Yes □ No □</p><p>Have you tried anything to help with your problem? Yes □ No □ (e.g. pain killers, exercise, other treatment)</p><p>Please specify:</p><p>Have you had Physiotherapy for the same problem in the last 6 months? Yes □ No □</p><p>If so, where did you have your Physiotherapy?</p><p>Are you suffering from any of the following:</p><p>MRSA □ C.diff □ diarrhoea & vomiting □ scabies □</p><p>Impetigo □ undiagnosed skin rash □ </p><p>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.</p><p>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</p><p>Contact Tel: 01634 833959 Fax: 01634 402877 Email: [email protected]</p><p>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.</p><p>Page 3</p>