Patient self-referral form

Patient/Carer Self Referral Form

"*" indicates required fields

Have you used the MSK Matters website or any other guidance to help you with your condition?*

Yes

Please select which sources you have used*

Other*

Please enter any other sources you may have used outside of the above options.

We would encourage you to use the advice, information and exercises available on this website to help you with your condition before considering referring yourself to the service at this time.

We are keen to learn how confident you are with using IT. Please select the option which best represents your confidence with IT

Confident

Difficulty Using

Limited Skills/No Access

Consent for referral

We understand how aches and pains in your joints, muscles and bones can cause frustration and worry, impacting on your daily activities. In most cases, these can be treated by yourself, in your own home using guidance available on this website.

If you continue to suffer with a condition or injury affecting muscles, joints and soft tissues such as low back pain, shoulder pain or neck pain, a Physiotherapist may be able to help.

You can refer yourself to see an NHS Physiotherapist by completing your details below.

Please confirm the following statements to continue. For any of the conditions listed below, your GP or Healthcare professional will refer you to these specialist services in their usual way.

I am registered with a Dorset GP.
I am not referring for a neurological condition (such as Stroke or MS).
I am not referring for a gynaecological condition (such as prolapse or incontinence).
I am not referring for a respiratory condition (COPD or cystic fibrosis).
I am not referring for a condition relating to pregnancy or birth (up to 12 months after birth). You can find information and self-refer to Maternity Physiotherapy via this link. If you are a healthcare professional, you can also use this link to refer on behalf of the patient.

I confirm all of the above are true*

I confirm this referral is for someone 16 years of age or over.*

Yes

I am a veteran*

Yes

Select your GP practice*

Please select your preferred physiotherapy team*

Name*

First Last

Date of birth*

Ethnicity*

NHS Number*

Find your NHS number

Address*

Street Address Address Line 2 City Post Code

Contact phone number*

Can we leave a message at the above contact number?*

Yes

Alternative contact phone number

Can we leave a message at the above alternative contact number?

Yes

Email address*

Enter Email Confirm Email

Can we contact you using the above email?

Yes

Do you have any additional communications needs?*

Yes

Please give details about additional communication needs

Do you require an interpreter?*

Yes

Which language do you require?

Which body part is affected (please select one)*

How long have you had this problem?*

Please mark level of pain on the scale 0 = no pain 10 = worst pain imaginable*

Please give a brief description of what the main problem is*

If you have started to develop any combination of the below symptoms or you had some previously but they are worse now, seek help immediately by either contacting your GP or attending hour local accident and emergency department

- Loss of feelings/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

Have you had any other symptoms, such as numbness, tingling or muscle weakness?

Yes

Please give details of your other symptoms

Thinking about the last 2 weeks, please mark your response to the following:

My back pain has spread down my leg(s) at some point in the last 2 weeks*

Agree

Disagree

I have had pain in the shoulder or neck at some time in the last 2 weeks*

Agree

Disagree

I have only walked short distances because of my back pain*

Agree

Disagree

In the last 2 weeks, I have dressed more slowly than usual because of my back pain*

Agree

Disagree

It's really not safe for a person with a condition like mine to be physically active*

Agree

Disagree

Worrying thoughts have been going through my mind a lot of the time*

Agree

Disagree

I feel that my back pain is terrible and it's never going to get any better*

Agree

Disagree

In general I have not enjoyed all the things I used to enjoy*

Agree

Disagree

Overall, how bothersome has your back pain been in the last 2 weeks*

Are you off work/unable to care for a dependent because of this problem?*

Yes

Are you able to carry out your normal activities?*

Yes

Are your symptoms worsening?*

Yes

Have you suddenly lost any weight without trying?*

Yes

Have you seen your GP about this problem?*

Yes

When did you see your GP about this problem?

What treatment have you had for this problem before? E.g. exercise, advice, Chiropractor

Please inform us of any significant previous or current medical conditions

Thank you for completing this self referral form which will be submitted to the NHS Outpatient Physiotherapy Service that you requested.

By submitting your personal information, you consent to NHS Dorset Clinical Commissioning Group (CCG) securely processing your personal data and transferring it to the appropriate physiotherapy service within Dorset. NHS Dorset CCG’s GDPR compliance is managed by our Data Protection Officer.

The purpose of this data is solely to being your physiotherapy referral process. We only submit the information you choose to give us, and we process it with your consent. We only require the minimum amount of personal information that is necessary to fulfill the self-referral service. We do not sell information to third parties. Your information will be securely transferred directly to physiotherapy services and be held in accordance with the Records Management Code of Practice for Health and Social Care. The retention of this data is managed by the physiotherapy services within Dorset.

As part of your referral, your information may be shared with our partnership NHS organisations in accordance with Section 3 of the Health and Social Care (Safety and Quality) Act 2015. Your information will only be shared if it is determined to be in your best interest and to ensure you the best care.

If you believe your data may have been misused or mishandled in any way you can report this to the Information Commissioner’s Office.

Having read the above, would you like confirmation of your referral by email?*

Yes

Hidden

Date