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 pain, please ask your GP/Midwife to refer you to the Pelvic Health/ Women’s Health Physiotherapy Service who do not currently accept self-referrals.

Physiotherapy Referral Form

"*" indicates required fields

Name*
DD slash MM slash YYYY
DD slash MM slash YYYY
Please be reminded that Direct access physiotherapy in SEHSCT is only available to prospective clients of 16 years and over.
Address*
Please enter your email address if you have access to an email account and wish to receive confirmation of your request.
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?*
Do you require an interpreter?*
Do you require adjustments for reasons related to a disability?*
GP Practice Address*
Did your GP suggest self-referral to Physiotherapy*
How long have you had this problem?*
This field is hidden when viewing the form
How long have you had this problem?
Have you seen your GP regarding this problem?*
Is this problem..*
Are the symptoms getting worse?*
Are you able to carry out your normal activities? (work, care for a dependant, sport)*
Do you know what caused your problem?*
Do you have any other medical condition or information that you think may be relevant e.g. Cancer, previous fractures, Diabetes, Osteoporosis?*
Have you lost weight in the past 6 months for reasons you cannot explain?*
Have you developed Numbness / Tingling / Pins and Needles since the start of your problem?*
Since the onset of your problem do you have any of the following symptoms?*
If you answered YES to any of the questions above and you HAVE NOT seen a doctor for this symptom, it is essential that you arrange for URGENT advice from your GP or attend your local Emergency Department DO NOT SEND IN THIS FORM UNTIL YOU HAVE SOUGHT FURTHER ADVICE
Please tick where you wish to attend for assessment*

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

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