Patient Self Referral to Musculoskeletal Physiotherapy

This form should only be used for patients over the age of 18 who are registered with an Islington or Haringey GP wishing to have Physiotherapy for musculoskeletal problems (back/neck pain, joint pain, soft tissue injuries).

Before you self refer to MSK Physiotherapy please do try this personalised online supported self management help: Whittington Health now have an easy, safe, and effective way to help you improve your musculoskeletal health without the need for a clinic appointment, through the getUBetter platform. This provides evidence-based advice for all common muscle, bone, and joint problems, including back, back and leg, neck, shoulder, hip, knee, ankle pain, soft tissue injuries and conditions. You can access the getUBetter platform via the QR code below or by clicking GetUBetter

Please ensure all the fields marked* are filled in correctly.

Please attach any additional relevant information

Please select which borough your GP is in * Haringey
Islington
Other

If Other, please specify

Patient details

Surname*

First name*

Date of Birth*(dd/mm/yyyy)

NHS Number(if known)

Click here Find your NHS number to confirm your NHS number

Address and Postcode*

Mobile*

Home number

Are you happy to receive information by email * Yes
No

Is an interpreter required?* Yes
No

Self-describe

Does this match the sex assigned at birth?* Yes
No

If no, what was your assigned sex at birth

Other

*We ask these questions to provide the best possible care. Biological sex can contribute differently to Musculoskeletal conditions and helps to inform us about which kind of appointment might best help you. The Trust is an open, non-judgemental and inclusive organisation that will not tolerate racism or discrimination. We celebrate the diversity of our staff and community.

Next of Kin

Next of Kin's Telephone number

Next of Kin's Relationship

GP details

Surgery Name*

GP Name

GP Address and Postcode*

GP Telephone number

Have you consulted your GP about this problem?* Yes
No

If Yes, what did they recommend

Additional Information

Give a brief description of your problem including how it started.(please only refer for one condition)*

Area of pain / How it started / Any pins & needles or numbness – if so, where?

Is this a new problem? * Yes
No - this is a flare-up of a previous problem
No – this is a long standing condition

How long have you had this problem?* Less than 2 weeks
2 – 6 weeks
More than 6 weeks
More than 1 year

Is your problem* Getting better
Getting worse
Staying the same

Have you had any previous treatment for this condition e.g. Osteopathy, Chiropractic Treatment

General Health - Please tick if you have any of the following:

Lung Problems

Heart Problems

Epilepsy

Osteoarthritis

Rheumatoid Arthritis

Diabetes

Surgery / Operations

Poor General Health

Previous Fractures

Anxiety/Depression

Pregnant

Any Major Illness

If Yes to any, please give details

Since the onset of this problem do any of the following apply to you? If you have the symptom(s) please tick

Severe pain, swelling or instability caused by a significant accident/injury in the last 2 weeks, which has not been assessed face-to-face by A&E or your GP.

Unexplained Weight Loss and a history of cancer

Fever or Night Sweats

Unexplained Bladder or Bowel problems, particularly

Loss of feeling/pins and needles between your inner thighs, genitals or back passage
Increasing difficulty when you try to urinate
Increasing difficulty when you try to stop or control your flow of urine
Not knowing when your bladder is either full or empty
Inability to stop a bowel movement or leaking
A recent onset of pain in both legs with any of the above

(*Consider an urgent appointment with your GP if symptoms are stable or attend your local A&E Department if these symptoms are new within the last few days or recently worsening. For further information follow this link:

https://www.macpweb.org/Resources/37b9fa6e-1b59-43fc-a2a3-d0a8f8430720)

Unremitting/constant Night Pain

A loss of coordination or strength in the arms or legs causing difficulty with walking or dextrous tasks like handwriting, texting or using zips and buttons.

If you have ticked any of these symptoms and you have not discussed them with a doctor, please arrange a review with your GP Practice. You will be unable to submit this form in the presence of these symptoms and a GP referral is needed. If any of the symptoms are new and severe, please consider attending A&E, if you are not sure, please call 111.

Please list any Medicine you are taking

Employment status* Employed
Unemployed
Retired
Student
Carer

Please give details*

Any activities you do (E.g. Sports, Gym, Hobbies). *

Due to your current problem you are unable to

Work

Participate in activity/sport

Care for dependent

Other

Please give details

What are your expectations from Physiotherapy?*

Have you use the Whittington Health Getubetter self management app to support with the management of this condition? * Yes
No

If you are unable to submit this form, please refer back to the section that starts ‘Since the onset of this problem do any of the following apply to you? If you have the symptom(s) please tick’. You are unable to submit this form if these symptoms are selected. If you have ticked any of these symptoms and you have not discussed them with a doctor, please arrange a review with your GP Practice. You will be unable to submit this form in the presence of these symptoms and a GP referral is needed. If any of the symptoms are new and severe, please consider attending A&E, if you are not sure, please call 111