Musculo-Skeletal First Contact Practitioner
Fill in this form to request an appointment with Helen Hilliard, our MSK practitioner who will assess you and arrange appropriate investigations.
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Telephone number
Please describe whereabouts on your body the problem is:
Please mark on the body chart where your problem is that you wish to discuss with the MSK practitioner. Please note that multiple problems may not all be dealt with in one appointment
What is the problem?
Pain / ache
Tinging / pins and needles
Numbness
Weakness
Stiffness
Swelling
How long have you had the problem for?
Less than 6 weeks
Less than 3 months
Less than 1 year
1-5 years
Over 5 years
Is this the first time you have had this problem?
Yes
No
If no, when did you last have this problem?
How many times have you had this problem before?
Is this a long-standing problem which is getting worse?
Yes
No
Unsure
Since this episode started, are your symptoms currently:
Better
Same
Worse
What is your preferred type of consultation?
telephone or video
face to face
Do you require an interpreter?
No
Yes
If yes, which language?
Do you have visual problems?
Yes
No
Do you have hearing difficulties?
Yes
No
Have you noticed any changes in your bowel or bladder control in the last month?
Yes
No
If yes, please describe
Have you noticed any loss of sensation between your legs, around your private parts or your back passage?
Yes
No
Have you noticed any weakness? e.g tripping up, floppy foot, dropping objects from your hand?
Yes
No
Submit
Should be Empty: