Physiotherapy Self-referral form

Self-Referral Form

Prior to completing this self-referral form please be advised that:

We can only accept self-referrals from patients (16 years or older) living within the Plymouth catchment area, who are registered with a Plymouth GP.
You must be seeking help with a Musculoskeletal problem, such as neck or back pain or soft tissue or joint problems such as strains and sprains.Further guidance can be found on our web page https://www.plymouthhospitals.nhs.uk/physio-self-referral
It is important you do not self-refer if you have any of the following conditions without consulting your GP
Unexplained weight loss, unexplained bladder or bowel problems, history of cancer, night pain, fever or night sweats, unsteady on feet or pins & needles/numbness in both arms or in both legs.

Can I refer for multiple problems?
We request that you refer for just one condition per referral. This is to keep waiting times down and improve the quality of your care.

Once a physiotherapist has completed care for this condition you may then refer again for something else if necessary.

Physio Self-referral

Note: Questions marked by * are mandatory

*This is a mandatory field. What is your full name

*This is a mandatory field. Are you

*This is a mandatory field. Do you require a physiotherapist of the same gender? Please select

Your date of birth (DD/MM/YYYY)

*This is a mandatory field. Your address

*This is a mandatory field. Your postcode

*This is a mandatory field. Preferred contact telephone number

Alternative telephone number

*This is a mandatory field. Can a message be left?

*This is a mandatory field. Your email address

*This is a mandatory field. NHS or hospital number

*This is a mandatory field. Is an interpreter required

If yes, what language

*This is a mandatory field. GP name and practice

*This is a mandatory field. GP telephone number

*This is a mandatory field. Have you consulted your GP about this problem

*This is a mandatory field. Did your GP suggest being referred to Physiotherapy

*This is a mandatory field. When did the problem start

*This is a mandatory field. What symptoms do you have

*This is a mandatory field. Is the problem: new, a flare-up of a previous problem, on-going long term problem?

*This is a mandatory field. And is it: getting better, getting worse or staying the same

*This is a mandatory field. What do you think happened to cause this problem

*This is a mandatory field. Have you had any investigations for this problem? e.g. scans, x-rays, blood tests

*This is a mandatory field. Have you had any previous treatment for this problem? e.g. medical treatment, physiotherapy, oesteopathy, chiropractic

*This is a mandatory field. What is your employment status?

*This is a mandatory field. Due to your current problem are you unable to take part in certain activities? e.g .work, participate in sport/activities, care for dependant, other etc.

*This is a mandatory field. Do you have any other medical condition or previous medical history e.g. surgery which may be relevant? e.g. pregnancy, diabetes, fractures etc.

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Self-referral Form

Self-Referral Form

Prior to completing this self-referral form please be advised that:

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