Self-Referral to Physiotherapy	               
Please complete all sections / tick boxes and email it to physioreferrals@cumbria.nhs.uk 
If you are unable to email, please post form to Carleton Clinic Physiotherapy Department, Cumwhinton Drive, Carlisle CA1 3SX  
Please ensure that your full name, full address and date of birth are on the top.   
Please note – incomplete forms may not be processed.
NHS Number 
Date of Birth 
Title
	First Name (in full)	Surname:
	
Date of Birth:  
	Today’s Date: 	
Address (including postcode):

Phone Number(s)
Home: 
Mobile: 	Consent to leave message including SMS text:        YES  NO  	
Email address:
	Do we have your consent to contact you via email?     YES  NO 	
GP Name and Practice:

	If required, do we have your consent to view your Medical Records?     YES  NO 	
Where would you prefer to be seen? (please tick) 
Carlisle – Carleton Clinic               Brampton – Cottage Hospital  	
What is your appointment preference? (please tick)
Face to face       Telephone       Video call  	

1.	Please give a brief description of why you need a physiotherapy assessment (include area of body affected):
      
2.	How long have you had this problem?      

3.	Has this problem previously been treated with physiotherapy?     YES  NO 
4.	Are the symptoms worsening?     YES  NO 
(If yes, please give details)      

5.	Are you able to carry out normal activities?     YES  NO 

6.	Are you off work/unable to care for a dependent because of this problem?     YES  NO         Not applicable   

7.	Please give details of any other treatment you have received for these symptoms:       
8.	Have you had any sudden weight loss without trying?     YES  NO 
	
9.	Have you had any other symptoms such as numbness, tingling or muscle weakness which is either new or related to your current problem?     YES  NO 
(If yes please give details)      

10.	Have you had any recent changes to your bladder and bowel habits or altered sensation in the genital/saddle area     YES  NO 
(If YES please see the information overleaf for advice and guidance).

11.	Please list any current or past medical conditions and bring the list to your first appointment i.e. heart conditions, high blood pressure, arthritis etc.       

12.	Please bring a list of your current medications to your first appointment. 

Not sure if Physiotherapy is right for you?
Physiotherapy can be particularly beneficial if you are suffering from back pain, neck pain, recent injuries such as strains or sprains or joint and muscular pain. You can also see a physiotherapist if you male/female suffering from incontinence.  
Unfortunately our self referral Physiotherapy service is not available if:
•	You want to see a physiotherapist about a neurological or breathing problem
•	You need a home visit
•	You are under secondary school age (if you are under 16 you will need a guardian to accompany you to the assessment)
•	If you want physiotherapy following a recent operation, for this you will need to be referred by your surgeon
Pain Relief?
Over the counter painkillers can be helpful. A pharmacist will be able to advise you on the appropriate tablets. If your symptoms worsen you may wish to see your GP. If you have an old injury, you may find that holding a hot water bottle wrapped in a towel on the affected area for 10 minutes reduces pain, while for a new injury you can use a pack of frozen peas wrapped in a damp towel for 10 minutes. Please be aware that hot and cold can burn and that you need to check every 5 minutes that your skin does not become very red or blotchy. If this happens, stop.

What can I do for myself in the meantime?
Research has shown that resting for more than a day or so does not help and may actually prolong pain and disability. You may need to modify your activities initially, but the sooner you can get back to normal activity the sooner you will feel better. Getting stiff joints and muscles working can be painful, but this is a normal response and not a sign of damage. Feeling a bit sore initially is also normal and often a good sign that you are making progress. Changing your position or activity frequently through the day will help to prevent and reduce stiffness. Try to build up your general activity gradually. The following links can also give you some useful advice whilst you are waiting

What happens next?
Complete the entire form (remember your name) and email it to physioreferrals@cumbria.nhs.uk.You will be called by a member of the team once we are able to offer you an appointment. 
Whilst you wait for your appointment you may find the following websites useful:www.nhs.uk/conditions, www.csp.org.uk/conditions
Further Guidance from Question 10 overleaf

***If you are experiencing or develop the above symptoms it is advised you seek emergency medical advice through your GP practice, NHS 111 or the A and E department***