PART ONE: Screening form for Self-Referral PLEASE COMPLETE THIS CHECKLIST TO SEE IF YOU ARE SUITABLE FOR SELF REFERRAL TO PHYSIOTHERAPY 1. Were you directed to this form by a health professional: GP, physiotherapist or nurse? If no, please contact your local GP surgery where you will be directed to the most appropriate physiotherapy service. NB: If you are a Courtyard Surgery patient, please continue to use this form. YesNo 2. Are you under 16 years old? YesNo 3. Are you filling in this form on behalf of someone else? YesNo 4. Has your general health changed recently in any way that you haven’t discussed with your GP? YesNo 5. Have you had a significant accident recently, for which you have not sought medical advice? YesNo 6. Is this problem to do with Your breathing/chest YesNo A neurological problem e.g. stroke or multiple sclerosis YesNo Incontinence YesNo 7. If you have back pain: since the pain came on have you developed any of the following symptoms Problems passing urine YesNo Problems controlling bowel movements YesNo Pins and needles or numbness between your legs or around your back passage YesNo If you have answered yes to any of the questions 2-7 above, you are not suitable to self-refer to physiotherapy. Please contact your GP practice to find out who is the best person to speak to or see regarding your problem/condition. Otherwise, please answer the questions below and proceed to PART TWO Consent to Data Sharing Do you consent to information recorded by us being shared with other health care professionals? YesNo Do you consent to this organisation viewing data relating to your care held on other GP systems? (GP, Out of hours, etc) YesNo From your records we will triage your referral. We may call you for more information if it is felt appropriate. PART TWO: Patient details for Self-Referral – PLEASE COMPLETE EVERY SECTION Date NHS Number (if known) Forename(s) Surname Previous Surname Title —Please choose an option—MrMrsMissMsReverand Sex —Please choose an option—MF Date of Birth Daytime telephone number Mobile telephone number Email Address Post code Can we leave a message via voicemail or text message YesNo GP Practice Please give us a brief description of where your problem is: How long have you had these symptoms? Were these symptoms GradualSudden Have you attended physiotherapy for the same condition in the last 6 months? YesNo Have you had any other treatments for this problem? (Include dates) Is your problem worsening? YesNo Are you able to continue your normal activities? YesNo Is this problem preventing you from working? YesNo Do you have any pins and needles or numbness? YesNo Is this problem waking you at night? YesNo Submit Δ
