Home Physiotherapy Self Referral Form

Physiotherapy Self Referral Form

Self-referral is available for adults over 16 who need support and advice to manage symptoms related to muscle strains/joint sprains/back and neck pain. This referral option is not available if you are under the care of a consultant for this problem, or if you have neurological/respiratory/continence conditions. If you have Pregnancy related pains, please ask your GP/Midwife to direct you to the appropriate service. If you have had recent orthopaedic surgery, please seek referral to physiotherapy via your GP or consultant.

Please note, self-referral is now available via the My Care App, helping you to manage your Healthcare needs in one place.

For further information on how to access, please follow this link – My Care – DHCNI

Self-Referral to MSK Outpatient Physiotherapy

"*" indicates required fields

If the referral form has been completed by somebody else on the patient's behalf, tick YES below to confirm the patient has consented to this referral being made.*

You must have consent to complete the form.

Yes - Tick only if completed on patients behalf

Completing for myself

Name*

First Last

Todays Date*

DD slash MM slash YYYY

Are you 16 years of age or older?*

Yes

Please note that Self-referral to Physiotherapy is only available to patients aged 16 years and over. If you are not yet 16 years of age you will not be able to refer yourself for this service.

Date of Birth*

Your must be 16 years or older to self-refer. If you are under 16 you will not be contacted.

DD slash MM slash YYYY

Are you referring following a fracture or surgery?*

Yes

If you are referring following a fracture or surgery you are unable to complete this form due to additional information being required about your condition. Please contact your GP to discuss a referral.

Address*

Street Address Address Line 2 City ZIP / Postal Code Country

Your Health and Care Number (if known)

Email*

Please enter your email address if you have access to an email account and wish to receive confirmation of your request.

Phone Number*

A telephone number is essential as this is the preferred method of communication with our service users. To ensure a timely response to your request for treatment, please ensure you have entered a telephone number where you can be contacted. If you do not have a home telephone number, please provide an alternative.

Can we leave a message at this number?*

Yes

Do you require an interpreter?*

Yes

Do you require sign interpretation?*

Yes

Do you require language interpretation?*

Yes

For which language do you require an interpreter?*

Do you require adjustments for reasons related to a disability?*

Yes

Add description of required adjustments*

GP Name*

GP Practice Address*

Street Address Address Line 2 City ZIP / Postal Code Country

Where do you wish to attend for assessment?*

Who recommended self-referral?*

Where is your main problem? Please only select ONE*

How long have you had this problem?*

0-6 Weeks

7 -12 Weeks

> 13 Weeks

> 1 Year

Have you seen your GP or anyone else in your GP practice about this problem?*

Yes

Is this problem...*

Are the symptoms getting worse?*

Yes

If yes, in what way?*

Are you able to carry out your normal activities? (work, care for a dependant, sport)*

Yes

If No what are you having difficulty with?*

Do you know what caused your problem?*

Yes

If yes, please give details*

Do you have any other medical condition or information that you think may be relevant e.g. Cancer, previous fractures, Diabetes, Osteoporosis?*

Yes

If yes, please give details:*

Please give us further information on your condition/injury. Sometimes we miss what is most important to you, what is concerning you most? It is helpful for us to have as much information as possible.*

Have you lost weight in the past 6 months for no apparent reason/that cannot be explained?*

Yes

If yes, how much?*

Have you developed Numbness / Tingling / Pins and Needles since the start of your problem?*

Yes

If yes, where?*

Since the onset of your problem do you have any of the following symptoms? (We appreciate some of these questions are personal but they are required to rule out some serious conditions)*

A new episode or a sudden change to your ability to control or to pass urine

A new loss of sensation to your inner thighs, genitals or back passage area

A new difficulty with Bowel function resulting in a loss of bowel control (soiling yourself)

None of the above

If you develop any of these new symptoms, after submitting this form, it is essential that you attend your local Emergency Department.

If you have answered YES to any of these questions and you HAVE NOT seen a doctor for this symptom, it is essential that you attend your local Emergency Department, DO NOT SUBMIT THIS FORM UNTIL YOU HAVE SOUGHT FURTHER ADVICE If you have any of these symptoms, please click here to watch this video to understand why immediate attendance at your local ED is essential.

While you are waiting if you are concerned that your condition is worsening please seek medical advice.

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Lisburn Primary and Community Care Centre

Physiotherapy Self Referral Form

Self-Referral to MSK Outpatient Physiotherapy

If you develop any of these new symptoms, after submitting this form, it is essential that you attend your local Emergency Department.

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