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

September 22, 2020

Trowbridge Minor Injury Unit to re-open for booked appointments

Trowbridge Minor Injury Unit to re-open for booked appointments The Minor Injury Unit... Read more >

September 10, 2020

Supporting patients with respiratory disease to keep active Wiltshire Health and Care... Read more >

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WiltsHealthAndCare@WiltsHC_NHS·

22 Sep

#Trowbridge Minor Injury Unit opens Monday 28 Sept. for patients who've contacted NHS 111 by phone or online & are referred for an MIU appointment. No ‘walk in’ patients please. This change in service is to keep patients & staff safe. Think NHS 111 First. https://bit.ly/3mGmwh1

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Public Health Wiltshire @PHWiltshire·

21 Sep

Help keep your eyes and vision healthy with the #EyeWeek 10 Best Eye Health Habits. Eating well, being active and not smoking are all important for maintain good eye health. Find out more here http://orlo.uk/www_visionmatters_org_uk_Y9k6l Because #VisionMatters

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