Hounslow Physiotherapy Self Referral

West London Physiotherapy Self Referral

Physiotherapy Self Referral
Please Read This Before Continuing

Please consult your GP or NHS 111 urgently if you have recently or suddenly developed:

• Difficulty passing urine or controlling bladder/bowels

• Numbness or tingling around the back passage or genitals

• Numbness, pins and needles or weakness in both legs.

Please discuss with your GP before submitting this referral if you:

• Are feeling generally unwell/fever

• Have any unexplained weight loss

• Have a history of cancer

• Have recently become unsteady on your feet.

If you have any difficulties with this form please call us on 0300 555 0107

If you have muscle pain, joint pain / stiffness, a sprain or strain, or back pain, please consider booking an appointment with your First Contact Practitioner Physiotherapist (FCP) in your GP surgery.

The FCP Physiotherapist will assess you and suggest the most appropriate way to help you. The FCP Physiotherapist can also give you advice about any further investigations or treatment, if you need them, or refer you to other services, including the Hounslow MSK Physiotherapy Service.

The FCP Physiotherapist could help you with:

Joint pain Shoulder pain             Tendon problems

Muscle pain                Sports Injuries            Foot pain/arch pain

Neck pain Soft tissue injuries      Tennis elbow

Back pain Osteoarthritis Knee problems

Trapped nerves Sciatica Hand/wrist problems

If you feel that you could benefit from seeing the FCP Physiotherapist for your problem, then please contact your GP surgery to arrange an appointment prior to self-referring to the Hounslow MSK Physiotherapy Service.

You may need to describe the problem to ensure that the physiotherapist is the right person for you to see.

However, if you would still like to self-refer to the Hounslow Physiotherapy Service, please click ‘Next’.

Physiotherapy Self-referral

Your name and contact details
Full Name*

First NameLast Name
Gender*

MaleFemalePrefer not to sayOther
Date of Birth*

DayMonthYear
Date
Email Address (if applicable)

Confirmation Emailexample@example.com
Address

Street Address

Street Address Line 2

City

Post Code
Contact Telephone Number (preferred contact phone number)*

Further Information
NHS Number*
Registered GP*
Are you able to attend an Outpatient Clinic?
Do you need an interpreter?
Language
Ethnicity
If other, please specify
Occupation
Off work due to this problem?
If you are currently off work due to this problem, how long have you been off work for?
Are you a registered carer?
Are you having difficulty caring for someone due to this problem?

Your symptoms
Describe fully your symptoms/ pain/ problem, (include odd sensations)*
Do you have any areas of skin that you are unable to feel when you touch yourself?
When and how did your symptoms start? (e.g 1 week ago lifting)*

About Your Symptoms
Are your symptoms:
If Other, please specify
Are your symptoms present:
If other, Please specify
Do you find the symptom disturbs your sleep:
If other, please specify
Are your symptoms:
If other, please specify

What Affects Your Symptoms
Please describe anything you have found that makes your symptoms worse
Please describe anything you have found that makes your symptoms easier
Please tell us if you have had any previous treatment for this problem, e.g. medical treatment, GP, Physiotherapy, Osteopathy, Chiropractic
Please tell us if you have had any investigations for this problem such as X-ray, MRI, blood tests, etc (including results)

New Episodes or Changes
Please let us know if you had any new episodes of or changes to

Swelling of a jointPainful clickingGiving-way of your leg or knee resulting in stumbling or fallingLocking of your knee resulting in you being unable to bend or straighten your leg, or having to physically 'unlock' your knee with your handsNone of the above
Please let us know if you have had any new episodes of or changes to? (Please add further appropriate information in the text box below)
Further information about existing medical conditions
Have you tried the GetUBetter App for this problem

Other Information
Please list all your current medications including any painkillers
Please tell us anything else you think maybe relevant to this referral

DECLARATION OF CONSENT
Name: of service user / legal guardian / lasting power of attorney:

First NameLast Name
I, consent to receiving e-mail correspondence and text alerts from the MSK physiotheraphy service regarding appointment information and general information regarding the service.
Email

YesNo
Text

YesNo
Name in capitals

First NameLast Name
Relationship to service user
Should be Empty: