Do you have any soft tissue lumps or bumps in the body part you are referring for?

Yes

No

[REMOVED] Have you had recent surgery on this body part?

Yes

No

Do you have any fever symptoms including night sweats, fatigue, weight loss or nausea?

Yes

No

Do you have any metalwork in the body part you are referring for? E.g. Knee, Hip replacement or any metalwork in situ around the area of your current symptoms.

Yes

No

[REMOVED] Do you have a history of trauma (or think you may have a tendon rupture)?

Yes

No

Do you have a history of cancer?

Yes

No

[REMOVED]Do you have a history of prostate, breast, kidney, thyroid or lung cancer?

Yes

No

[REMOVED]Did you have spinal cancer?

Yes

No

What treatment did you have? Did you need major/radical surgery, radiotherapy or chemotherapy?

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Do you have band like pain (pain around your torso)?

Yes

No

Are you unwell (fatigue / nausea / fever / stomach pain)?

Yes

No

Do you have mid back (thoracic) pain?

Yes

No

Are you experiencing altered sensation or weakness in your arms or legs? Do you feel uncoordinated or are losing your mobility?

Yes

No

Have you had any weight loss equal to 5-10% body weight over 3-6 months?

Yes

No

Select body region

If you are referring for several problems, please select one area at a time. You will have the option of making another referral after this one. We process referrals one condition at a time to make sure you are seen by the right person for each condition.

Neck pain
Neck and arm pain
Thoracic (mid back) pain
Low back pain
Low back and leg pain
Shoulder pain
Elbow pain
Hand or wrist pain
Hip pain
Knee pain
Foot or ankle pain
None of the above

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Have you had a significant trauma in the last 2 weeks which caused deformity, significant swelling or bruising?

Yes

No

Have you had a significant trauma in the last 2-4 weeks which caused deformity, significant swelling or bruising?

Yes

No

Have you had a significant trauma in the last 4+ weeks which caused, significant swelling or bruising?

Yes

No

[REMOVED]Do you have widespread body pains?

Yes

No

Since the onset of your back pain, have you experienced any of the following symptoms?

1. Loss of feeling or pins and needles between your inner thighs or genitals?
2. Numbness in or around your back passage or buttocks?
3. Increasing difficulty when you try to urinate or try to control your flow of urine?
4. Loss of sensation when you pass urine or pass a bowel motion?
5. Not knowing when your bladder is either full or empty?
6. Bladder or bowel incontinence?

Yes

No

If you need other language options please copy this link into a separate internet tab:
Cauda Equina Information cards (macpweb.org)

[REMOVED]Do you have early morning stiffness lasting more than 30 minutes?

Yes

No

[REMOVED]Do you have persistent swelling of one joint or more?

Yes

No

[REMOVED]If you squeeze the joints are they painful?

Yes

No

[REMOVED]Do you experience night pain?

Yes

No

Select the option that most closely matches your symptoms

Constant unrelenting, stops me getting to sleep

Wakes me up and stops me getting back to sleep

Painful when repositioning in bed but I can get back to sleep

Bit uncomfortable but I can get to sleep / uncomfortable when I wake in the morning

Have you had physiotherapy for this problem before?

Yes

No

Have you had a minor trauma which did not cause swelling, deformity or bruising?

Yes

No

In the last 2 weeks, have you had troublesome joint or muscle pain in more than one part of your body?

Yes

No

In the last 2 weeks, have you only been able to walk short distances because of your pain?

Yes

No

In the last 2 weeks, have you had to dress more slowly than usual because of your pain?

Yes

No

Do you have any other important health problems?

Yes

No

Do you feel it is unsafe for a person with a condition like yours to be physically active?

Yes

No

Have you had worrying thoughts about your pain a lot of the time in the last two weeks?

Yes

No

Do you think your pain condition will last a long time?

Yes

No

In the last two weeks, have you stopped enjoying all the things you usually enjoy?

Yes

No

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

Not at all

Slightly

Moderately

Very much

Extremely

What treatment did you have?

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Did the physiotherapy help?

Yes

No

If you are a military veteran or on active service, is this injury related to time served in the military?

Yes

No

If you are employed, are your symptoms affecting your ability to work?

Yes

No

If you are the main carer for someone else, are your symptoms affecting your ability to provide care?

Yes

No

[REMOVED] Since the onset of your back or neck pain, have you noticed any profound weakness in your arm or leg?

Yes

No

Did your back pain start when you were aged younger than 40?

Yes

No

Did your back pain develop gradually?

Yes

No

Does your back pain improve with movement?

Yes

No

Do you find there is no improvement in your back pain when you rest?

Yes

No

Do you suffer from back pain at night which improves when you get up?

Yes

No

Have you had symptoms for:

More than 16 weeks

Less than 16 weeks

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

Yes

No

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

Yes

No

I have only walked short distances because of my back pain

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Not at all

Slightly

Moderately

Very much

Extremely

Do you have a pregnancy related problem?

Yes

No

Have you seen anyone from your GP Practice about the same problem?

Yes

No

When did you see your GP Practice about this problem?

Today

Last few days

Within the last week

Within the last month

Over a month ago

Have you had surgery on the body part you are referring for in the past 6 weeks?

Yes

No

Have you had surgery on the body part you are referring for in the past 6 weeks?

Yes

No

When and where did you have your surgery? What operation did you have?

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Have you had pain, numbness or pins and needles down your arm or into your hand in the last 2 weeks?

Yes

No

Patients with a history of cancer may require a GP referral to access the musculoskeletal physiotherapy service.

Please provide further information below. One of our team will review this information and write to you if the referral is rejected. Which type of cancer did you have? When was your diagnosis?

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Thank you for self-referring to physiotherapy. We need to check we are the right team to assist you.

Do you have any of the following?

A new lump or bumpA pregnancy related problemA fever or feel unwellUnexplained weight lossDoes your condition mean that you are unable to put your full weight through your leg following recent trauma (e.g. a fall)?A red, hot and swollen jointMetalwork in the body part you are trying to self-refer forSurgery in the past 6 weeks on the body part you are trying to refer forNone of the above

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Which side is affected?

Left

Right

Both

Which side is affected?

Left

Right

Both

How long have you had symptoms?

Less than 6 weeks

6-16 weeks

More than 16 weeks

Please give a brief description of your problem.

Continue

Please give a brief description of your problem.

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Your details

Submit referral

Please wait while we submit your referral

Start a new referral

Send me a confirmation email

BMI

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Thank you for your referral.

While physiotherapy is appropriate for the majority of people, there some exceptions that we would ask that you see a Doctor first. Given the information you have provided, we would advise you contact your GP to discuss these symptoms. This referral has been rejected at this time. If your GP feels it is appropriate they can refer direct to physiotherapy.

We are unable to process this referral and you will require a referral directly from your GP. Apologies for the inconvenience

Thank you for your referral.

While physiotherapy is appropriate for the majority of people, there some exceptions that we would ask that you see a Doctor first. Given the recent history of trauma and deformity, swelling or bruising, we are unable to process this referral. We would advise you attend your local A&E department for an assessment of your symptoms and to exclude a significant injury.

Thank you for your referral.

While physiotherapy is appropriate for the majority of people, there some exceptions that we would ask that you see a Doctor first. Given the symptoms you are reporting, we are unable to accept this referral and we recommend you discuss these symptoms with your GP.

Thank you for your referral.

While physiotherapy is appropriate for the majority of people, there some exceptions that we would ask that you see a Doctor first. Given the symptoms you have described we are unable to process this referral. We would advise you discuss your symptoms with your GP prior to referring to physiotherapy.

Thank you for your referral.

Although it’s rare, the symptoms you have reported could be a sign of cauda equina syndrome. This is a rare back problem that can lead to permanent damage and disability. We recommend you immediately call 111 to discuss your symptoms. We are unable to accept this referral based on the symptoms you have reported.

Thank you for your referral.

While physiotherapy is appropriate for the majority of people, there some exceptions that we would ask that you see a Doctor first. As you have described significant weakness, we would advise you contact your GP urgently to discuss these symptoms. This referral has been rejected at this time.

Thank you for your referral.

The musculoskeletal service does not manage pregnant patients with back/pelvic pain or patients with back/pelvic pain less than three months following child birth. Pregnant patients or patients who have recently given birth (less than 3 months ago) are managed by the Women’s Health Physiotherapy team. This team does not accept self-referral and you need a referral direct from your GP. Apologies for any inconvenience caused.

Thank you for your referral.

Self-referral to physiotherapy is only available for patients over the age of 17. Patients 16 and under can access the paediatric physiotherapy service via their GP.

Thank you for your referral it has been received

If you would like email confirmation, please enter your email and press submit.

Please note we have received your referral and there is no need to contact your GP for a second referral.

Our admin team will be in touch with you when an appointment is available.

Submit

Start an additional referral

Please wait while we send your confirmation email

Start an additional referral

Please be aware that lumps and bumps are an exclusion criteria for the musculoskeletal service. One of our team will review the information you provide. If we are not the most appropriate service to manage this problem we will write to you to inform you that the referral has been rejected. Please use the box below to provide further information. Where is the lump? How big is the lump? Is it painful to press? Has it increased in size?

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Please be aware that these symptoms may need reviewing by your GP. Please provide further information below for one of our team to review. If we are not the most appropriate service to manage these problems we will write to you to inform you the referral has been rejected. Which of these symptoms do you have? How long have you had them for? Can you think of a reason why you have these symptoms?

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Patients with pregnancy related problems are managed by the Pelvic Health Physiotherapists. If you are pregnant or have given birth less than 3 months ago then your GP or Midwife can refer you to this team. The Women’s health team do not accept self-referrals. If you are more than 3 months post pregnancy then please return to the previous screen and leave the box unticked to complete the self-referral. One of our team will review the information and write to you if we are not the right team to manage your problem.

Continue

Please provide more information to assist with getting you to the correct place. When did the injury occur? What happened? Can you move the body part well? Patients with a recent history of trauma may not be appropriate for the musculoskeletal physiotherapy team. One of our team will review this information and write back to you if the referral has been rejected. Please continue to complete the self-referral form.

Continue

Please provide more information to assist with getting you to the correct place. When did the injury occur? What happened? Can you move the body part well? Patients with a recent history of trauma may not be appropriate for the musculoskeletal physiotherapy team. One of our team will review this information and write back to you if the referral has been rejected. Please continue to complete the self-referral form.

Continue

If you have a history of cancer we may ask that you see your GP to make sure you are being referred to the correct team. Please provide further details. Your answers will be reviewed and we will let you know if you need to see your GP first.

Which type of cancer did you have?

Continue

Thank you for your referral.

While physiotherapy is appropriate for the majority of people, there some exceptions that we would ask that you see a Doctor first. Given the information you have provided, we would advise you contact your GP to discuss these symptoms as pain at the site of metalwork is an exclusion criteria for the physiotherapy service. This referral has therefore been rejected at this time. If your GP feels it is appropriate they can refer direct to physiotherapy.

Please provide more information to assist with getting you to the correct place. When did the injury occur? What happened? Can you move the body part well? Patients with a recent history of trauma may not be appropriate for the musculoskeletal physiotherapy team. One of our team will review this information and write back to you if the referral has been rejected. Please continue to complete the self-referral form.

Continue

Given the information you have provided, we are unable to accept your self-referral. Please contact your GP who can refer for physiotherapy if they feel it is appropriate.
We understand this may feel like an extra step and appointments may be difficult. We ask this so we can attempt to reduce further delays and appointments with the wrong clinician.

Patients with pregnancy related problems are managed by the Pelvic Health Physiotherapists. If you are pregnant or have given birth less than 3 months ago then your GP or Midwife can refer you to this team. The Women’s health team do not accept self-referrals. If you are more than 3 months post pregnancy then please return to the previous screen and leave the box unticked to complete the self-referral. One of our team will review the information and write to you if we are not the right team to manage your problem.

When was your diagnosis?

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