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).

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

Please attach any additional relevant information

 

Patient details

 
 
 
 
   
 
 

 
 



 
 

*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.

GP details

 
   
 

Additional Information

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

 


 

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


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

  • 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)

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.


 



 
 
Due to your current problem you are unable to