Physiotherapy Self Referral Form

Patient Details

Please use this format: DD/MM/YYYY
Do you need an interpreter?
(please note it is not trust policy to use family or friends)

About Your Problem

We will only see you for one problem. If you have more than one problem please put it on a separate referral.
Have you previously had physiotherapy for this problem within the last 6 months?
Have you had any investigations or surgery relating to this problem?

About Your Current Symptoms

Have you recently had any episodes of loss of control with your bowel or bladder which the GP is unaware of?
Book an urgent appointment to see your GP before continuing with this referral.
Is your sleep pattern significantly disrupted by this problem?
Are you off work or restricted in your work duties because of this problem?
Is this problem affecting your ability to care for someone?