Test Form

29 June 2024

Step 1 of 23

    Self-Referral to MSK Physiotherapy Service

    Musculoskeletal (MSK) physiotherapy involves the assessment and treatment of muscles, tendons, ligaments, bones, joints, nerves and other structures in order to:

    • improve your movement and strength.

    • help you to do more of your normal activities.

    • help you to understand and manage your condition.

    Treatment is likely to include an exercise program specific to your needs.

    We are unable to accept a self-referral under certain circumstances. Please read and answer all of the following questions.

    MSK Physiotherapy may not help if you:

    • have had physiotherapy treatment for the same condition within the past year.

    • are referring yourself for widespread aches and pains.

    • have previously attended the Pain Clinic for the same condition.

    Please consult your GP URGENTLY or NHS 111

    Call NHS 111 on tel. no. 111

    If you have recently or suddenly developed:

    • difficulty passing urine or controlling bladder / bowels

    • numbness or tingling around your back passage or genitals

    • numbness, pins and needles or weakness in both legs

    Please inform your GP of this self-referral if you:

    • have recently become unsteady on your feet

    • are feeling generally unwell / fever

    • have a history of cancer

    • have any unexplained weight loss

    Consent to Data Sharing

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

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

    By submitting this form you’re consenting to your details/info being shared with other health care professionals.

    From your records we will triage your referral. We may call you for more information if it is felt appropriate.

    If you experience any issues completing our Self-Referral online form, you can download and fill in our Self-Referral Form. (Paper copies of the self-referral form are also available from your local physiotherapy department or GP surgery) Please deliver or post your completed form to your local physiotherapy department or email it to us at whc.mskphysiobookingcentre@nhs.net

    Are you registered with a GP who is within the Wiltshire Area?

    Are you under 16 years of age?

    Has your general health significantly changed recently in any way that you haven’t discussed with your GP?


    Please discuss these changes with your GP to determine who is the best person to see regarding your problem.

    Have you attended Accident and Emergency or Minor Injuries Unit within the past 2 weeks for your condition?

    Is this problem to do with:

    • Your breathing/chest

    • A neurological problem e.g. stroke or multiple sclerosis

    • Incontinence

    What is your name and gender?





    What is your date of birth?

    What is your occupation?


    What is your address?






    What are your contact details?

    You must provide at least one method of contact.





    What is your GP’s name and address?

    You must provide at least one method of contact.




    What is your first language?

    Do you require an interpreter?

    Please note that family members are not able to act as interpreters.


    We cannot always guarantee this but we’ll do our best

    Do you have any other special requirements?


    Using the diagram below, please select the location of your main problem. Use as many tick boxes as you need?

    Body Parts

    1. Head
    3. Right Shoulder
    5. Right Elbow
    7. Right Wrist/Hand
    9. Left Upper Arm
    11. Left Lower Arm
    13. Upper Back
    15. Right Buttock
    17. Right Thigh
    19. Right Lower Leg
    21. Left Buttock
    23. Left Thigh
    25. Left Lower Leg
    27. Front of Chest

    2. Neck
    4. Right Upper Arm
    6. Right Lower Arm
    8. Left Shoulder
    10. Left Elbow
    12. Left Wrist/Hand
    14. Lower Back
    16. Right Groin/Hip
    18. Right Knee
    20. Right Ankle/Foot
    22. Left Groin/Hip
    24. Left Knee
    26. Left Ankle/Foot
    28. Abdomen

    As your problem relates to the spine, have you experienced any of the following:

    • Numb clumsy hands (pins and needles or a ‘fizzing’ feeling)

    • A sensation of ‘heaviness’ in the legs

    • Inability to walk at a faster pace

    • Balance issues (such as unsteadiness and stumbling when walking or knocking into things – rather like if you were ‘drunk’)

    • Difficulty with fine motor skills (such as handwriting or buttoning a shirt)

    YesNo

    As your problem relates to the spine, have you experienced any of the following:

    • Loss of feeling/pins and needles between your inner thighs, or genitals

    • Numbness in or around your back passage or buttocks

    • Altered feeling when using toilet paper to wipe yourself

    • Increasing difficulty when you try to urinate

    • Increasing difficulty when you try to stop or control your flow of urine

    • Loss of sensation when you pass urine

    • Leaking urine or recent need to use pads

    • Not knowing when your bladder is either full or empty

    • Inability to stop a bowel movement or leaking

    • Loss of sensation when you pass a bowel motion

    • Change in ability to achieve an erection or ejaculate

    • Loss of sensation in genitals during sexual intercourse

    YesNo

    Brief description



    How long have these symptoms been present?



    Was the onset of this problem gradual or sudden?



    Have you had any previous treatments or investigations for your problem?


    Please provide details of any current or past medical conditions and medications you take



    Are you currently signed off work related to this problem?


    Are you a carer and unable to provide care because of this problem?


    What is your preference for your initial appointment?