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Services A - Z

Help in a crisis

Southern Health NHS Foundation Trust

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Physiotherapy form

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Physiotherapy
Physiotherapy form

I confirm I am 18 years or over (We are unable to accept self-referrals from under 18’s, your GP will need to make this referral) Required

Yes

What is your GP practice name Required

Please consult NHS 111 or your GP urgently 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 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

I confirm that I have read the screening information above Required

Yes

Patient information

Your first name Required

Your last name Required

Your date of birth Required

Europe/London

Your email Required

Your phone number Required

Are you happy for us to leave a message on this number? Required

Yes

Your address

Address 1

Address 2

City

Country

County

Postal Code

Your NHS number Required

If you dont know your NHS number you can find it here

Next of Kin details

Name

Relationship

Address (first line and postcode)

Phone Number

Are you pregnant Required

Yes

No

Do you have any special requirements (ie. Interpreter/BSL) Required

Yes

No

If yes please let us know

Have you recently seen or spoken to another health professional about this problem? Required

Yes

No

If yes, who did you speak to and what did they say?

Please describe your current problem and symptoms below

Please provide a brief description of the issue you are having including location of pain, swelling, stiffness, pins and needles, weakness etc Required

What are your expectations for this referral? Required

When do you experience pain? Required

All of the time

Some of the time

Activity related

Do you wake up at night because of pain? Required

No

Some nights

Most nights

How long have you had this problem? Required

Days

Weeks

Months

Years

Is your problem getting…? Required

Better

Worse

No change

Have you had any tests for this problem? Required

X-Ray

Bloods

MRI

Ultrasound scan

None

Have you had treatment for this problem? If yes please tell us what treatment you had.

Are you currently off work with this problem? Required

Yes, days

Yes, weeks

Yes, months

No

N/A

Are your day to day activities affected by your pain? Required

Not at all

Sometimes

All the time

If you would like to receive receipt of this form, please enter your email address below

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Southern Health is proud to be a University Hospital Trust.

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Southern Health NHS Foundation Trust
Sterne 7, Tatchbury Mount, Calmore, SO40 2RZ
Telephone: 02382 310000

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