How to access

How To Access – Part 2

Patient details for Self-Referral

This form is part 2 of the self referral form. if you have not filled out part 1 of the form, you can do so here: Form Part 1

Consent to Data Sharing

Do you consent to information recorded by us being shared with other health care professionals?

Yes

Do you consent to this organisation viewing data relating to your care held on other GP systems? (GP, Out of hours etc)

Yes

Personal Information

Date

Forename(s)

Surname

Previous Surname

Date Of Birth

Contact Details

Daytime Tel No

Mobile No

Can we leave a message?

Yes

Address

Post Code

NHS Details

NHS Number Format: 000 000 0000

GP Practice

Symptom details

Please give us a brief description of your problems or symptoms:

How long have you had these symptoms:

Have you had any other interventions or treatments for this problem? (Include dates)

Additional Questions

Did your GP suggest you complete this form?

Yes

Is your problem worsening?

Yes

Are you able to continue your normal activities?

Yes

Is this problem preventing you from working?

Yes

Are you self-referring to physiotherapy for low back pain or sciatica?

Yes

Back Pain Management Class: Activate Your Back (one-off class)

Yes

Back Pain Management Class: Back class (six week course)

Yes

One-to-One Physiotherapy Appointment

Yes

Telephone Appointment

Yes

The Keele Start Back Screening Tool Thinking about the last 2 weeks tick your response to the following questions:

1. My back pain has spread down my leg(s) at some time in the last 2 weeks

Agree

Disagree

2. I have had pain in the shoulder or neck at some time in the last 2 weeks

Agree

Disagree

3. I have only walked short distances because of my back pain

Agree

Disagree

4. In the last 2 weeks. I have dressed more slowly than usual because of back pain

Agree

Disagree

5. Its not really safe for a person with a condition like mine to be physically active

Agree

Disagree

6. Worrying thoughts have been going through my mind a lot of the time

Agree

Disagree

7. I feel that my back pain is terrible and its never going to get any better

Agree

Disagree

8. In general I have not enjoyed all the things I used to enjoy

Agree

Disagree

How you can get involved Give us your feedback Video consultations Virtual care home Staff area

Latest news

November 25, 2020

16 Days of Action: Increasing awareness of domestic abuse in young people

Over the next 16 days we will be helping to raise awareness of domestic abuse in young... Read more >

November 17, 2020

Celebrating our long serving volunteers

At this time of year we celebrate our long serving volunteers who have dedicated their... Read more >

> All news

Twitter

WiltsHealthAndCare@WiltsHC_NHS·

We are also supporting #16DaysofAction and sharing information with our staff and patients. More details including were to go for help and support across #Swindon and #Wiltshire available here https://bit.ly/2Vd4bf7

Wiltshire Council #WiltshireTogether@wiltscouncil

What are healthy and unhealthy relationships?

This year during #16DaysOfAction on #DomesticAbuse we’re focussing on young people and their relationships.

Reply on Twitter 1331515069230886913 Retweet on Twitter 1331515069230886913 Like on Twitter 1331515069230886913 Twitter 1331515069230886913

Retweet on Twitter WiltsHealthAndCare Retweeted

Lisa Hodgson @COO_WiltsHC_NHS·

20 Nov

So proud of every member of @WiltsHC_NHS & all partners across @BSW_STP a really busy week with triple the demand of last year but still smiling & putting out people (staff & public ) first 👏👏👏

Reply on Twitter 1329834422443634691 Retweet on Twitter 13298344224436346912 Like on Twitter 132983442244363469124 Twitter 1329834422443634691

> View all tweets

Not at all	Slightly	Moderately	Very much	Extremely

Wiltshire Health and Care

Enabling people to live independent and fulfilling lives

How to access

How To Access – Part 2