<p> OUTPATIENT AND WOMEN’S HEALTH PHYSIOTHERAPY REFERRAL FORM </p><p>Note: This referral form is for Outpatient Women’s Health and Musculoskeletal Physiotherapy only. For details regarding how to refer to other Physiotherapy or the Musculoskeletal Centre and FAQs please visit our website (www.schs.nhs.uk) Please complete this form in full as incomplete/illegible forms will be returned which will delay the referral PATIENT DETAILS Title: Forename(s): Surname(s): </p><p>M F NHS Number: D.O.B: Address (incl. postcode): </p><p>Daytime contact number: Alternative contact number: (We may contact the patient from a withheld number to discuss this referral) Is an interpreter required: NO YES If yes, which language: Does the patient have a learning disability? ETHNICITY White British Any other mixed background Black/Black British Caribbean White Irish Chinese Black or Black British African Any other White Asian or Asian British Indian Any other Black groups Mixed: White/Black Caribbean Asian or Asian British Bangladeshi Any other ethnic group Mixed: White & Black African Asian or Asian British Pakistani Declined to state ethnicity Mixed: White & Asian Any other Asian background REFERRER DETAILS Date of referral: GP/Consultant/Referrer Name: Contact Number: Fax Number: Address: NHS.net email address: GP Practice: TRIAGE PLEASE INDICATE BODY PART(S): SPINAL UPPER LIMB LOWER LIMB REFERRAL REASON/DIAGNOSIS AND RELEVANT MEDICAL HISTORY OR ATTACH EMIS REPORT (If post-operative: Operation details including a copy of op notes, post-op instructions and date of surgery are ESSENTIAL) (If post-fracture: Date of fracture and mobilising instructions are ESSENTIAL) </p><p>PLEASE TICK THE BOXES THAT BEST DESCRIBES THIS PATIENT: U30 NON-SPINAL SURGERY OR A FRACTURE IN THE LAST 12 WEEKS? U SPINAL SURGERY OR A FRACTURE IN THE LAST 12 WEEKS? U INJURY/TRAUMA IN THE LAST 6 WEEKS U ACUTELY OFF WORK (LESS THAN 6 WEEKS) DUE TO THIS PROBLEM U PATIENT IS A REGISTERED CARER AND THE SYMPTOMS ARE AFFECTING THEIR CARING CAPABILITY U CORTICOSTEROID INJECTION IN THE LAST 2 WEEKS U DIAGNOSIS BY PAIN CLINIC OF CRPS WHCP P PREGNANCY RELATED PAIN AND ≥34/40 WH(P)BACK PREGNANCY RELATED BACK INCONTINENCE OR PAIN WH(P)SPD PREGNANCY RELATED PELVIC PAIN _____/40 PELVIC ORGAN EDD: _____/_____/_____ {INTERPRETER=1:1} PROLAPSE PTA REQUIRES EQUIPMENT PROVISION ONLY (SPLINT, STICK OR CRUTCHES) R NONE OF THE ABOVE DOES THE PATIENT REQUIRE AN APPOINTMENT WITHIN:</p><p>5 WORKING DAYS? YES NO IF YES PLEASE INDICATE REASON: </p><p>OTHER SPECIFIC TIME (E.G POST-SURGERY?) YES NO IF YES PLEASE STATE TIMEFRAME: </p><p>PLEASE NOTE: PATIENTS WHO HAVE HAD UNSUCCESSFUL PHYSIOTHERAPY FOR THE SAME CONDITION WITH NO SIGNIFICANT CHANGE IN THEIR CIRCUMSTANCES ARE UNLIKELY TO BENEFIT FROM RE-REFERRAL. PLEASE CONSIDER REFERRAL TO PAIN CLINIC, COPE OR ORTHOPAEDICS Please return this referral form to the Sutton Adult Referral Centre: Email: [email protected] Fax: 020 3458 5888 Telephone: 0845 567 2000</p><p>OPY/WH REFERRAL FORM VERSION 3 FEB 2014</p>