Hillbrow Health & Wellbeing Physiotherapy Self Referral Form
Your Details
Full Name
*
Title
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
Date
Contact Number
*
Please enter a valid phone number.
Format: 00000 000000.
Email Address
*
example@example.com
Address
Street Address
Street Address Line 2
Town
County
Post Code
Back
Next
Health Details
Your GP Surgery:
NHS Number
Your Height:
Your Current Weight:
Assigned sex at birth:
Gender:
Are you pregnant?
No
Yes
How many weeks pregnant are you currently?
What's wrong?
Please state where you experience your main problem:
Which side of the body are you getting the problem?
How long have you had your current problem?
Tell us about the problem you are seeking help (Please describe how and why it started, whether a pre-existing injury, do you have pain, do you have weakness or changes in sensation e.g. numbness, pins and needles):
What do you hope to achieve with this referral?
Is your Problem getting worse, staying the same or getting better?
Getting worse
Staying the same
Getting better
Are you in significant, debilitating pain which means you are unable to walk, sleep or sit for long periods of more than 15 minutes?
Does your problem prevent you from being independent?
Does anything make your problem worse?
Does anything ease your problem ?
Have you been seen by another physiotherapist or therapist for help with this problem in the last 18 months?
No
Yes
How many times were you seen?
Does your issue relate to neck pain?
Yes
No
Does your issue relate to back problems?
Yes
No
Back Problems
Have you been unable to or had difficulty passing urine following the onset of back pain?
Have you been unable to stop/control your bowel/bladder following the onset of your back pain?
Have you had numbness or tingling around your genitals or back passage following the onset of back pain?
Neck Pain
Have you experienced any headaches or dizziness?
Noticing that you are dropping things or becoming clumsy?
Have you experienced any visual problems e.g. double vision, tunnel vision, blurred vision etc:
Have you had episodes of feeling unbalanced?
Have you experienced any change of sensations in your hands e.g. tingling, numbness, pins and needles:
Medication
Please detail your current medications:
Tests/Investigations
Have you had any scans or X-rays over the past 18 months?
No
Yes
Please indicate where and when these were done:
Are you happy for us to obtain results for any other investigations you previously have had:
No
Yes
Please indicate any medical conditions you have:
Have you been diagnosed with cancer?
No
Yes
Please give details regarding your cancer diagnosis:
Have you experienced any unexplained weight loss (over 5% of your body weight) over the past 12 months?
No
Yes
Submit
What date and time work best for you?
Do you need an interpreter?
No
Yes
Do you require/need a chaperone/advocate for your appointment
No
Yes
What services are you interested in?
Are you happy being contacted by the Hillbrow Health and Wellbeing team?
Yes
No
Should be Empty: