OUTPATIENT ANDWOMEN’S HEALTHPHYSIOTHERAPY REFERRALFORM

Note:This referralform is for Outpatient Women’sHealth and MusculoskeletalPhysiotherapyonly. Fordetails regardinghowtoreferto otherPhysiotherapyorthe MusculoskeletalCentreand FAQs pleasevisit ourwebsite (

Please see page 2 for furtherdetailsregarding other therapyservicesavailable and a guide on which service ismostappropriate

Pleasecompletethis forminfullasincomplete/illegibleformswillbereturnedwhichwill delaythereferral

PATIENTDETAILS

Title: / Forename(s): / Surname(s):
M / F / NHSNumber: / D.O.B:

Address(incl.postcode):

Daytimecontactnumber:

(Wemay contact the patient from a withheldnumber todiscussthisreferral) Alternativecontactnumber:

Wemaycontactpatientsfromawithheld number so it isimportant forpatientsto be awareof this so theyare lesslikelyto ignorethe call. Wewillnot leave voice messagesin line with information governance policy

IsanInterpreterrequired: NO YES If yes,whichlanguage: Doesthepatienthavea learningdisability?

ETHNICITY

It isimportant to complete thissection. Recordingofethnicityisimportant in order to tackle health inequalitiesandunderstand themedicalneedsofminority

communities

White British / Any othermixed background / Black/Black BritishCaribbean
WhiteIrish / Chinese / Blackor Black BritishAfrican
Any otherWhite / Asian orAsian BritishIndian / Any otherBlackgroups
Mixed: White/BlackCaribbean / Asian orAsian British Bangladeshi / Any other ethnicgroup
Mixed: WhiteBlackAfrican / Asian orAsian BritishPakistani / Declinedto state ethnicity
Mixed: White Asian / Any otherAsian background
REFERRERDETAILS
DateofReferral:
This information allows / us to ensure our GP/Consultant/ReferrerName:

referral process is carried out in a timely

manner

ContactNumber: FaxNumber:

Address:

It isessential thatwehavethecorrectaddressofthereferrerinorderto facilitatecommunicationregarding thereferral

NHS.netemailaddress: GPPractice:

TheNHS.netemailaddress(e.g. genericPracticeNHSnetaddress)

ofthereferrerallowsustocommunicatesecurelyandeasilywith thereferrer

Wearecommissionedtoseepatientsonly underthecareofa Sutton GP. Referrals for patients who are not registeredwithaGP inSutton cannotbeaccepted

TRIAGE

PLEASEINDICATEBODYPART(S): SPINAL UPPERLIMB LOWERLIMB OTHER(Pleaseindicate)

This informationisimportantinorderto ensurepatientsaretriagedontoan appropriateclinical pathwayandwecanmonitor theclinical needsofourpatientsasawhole

REFERRALREASON/DIAGNOSISANDRELEVANTMEDICALHISTORYORATTACHEMISREPORT

(Ifpost-operative: Operation details includinga copyofop notes,post-op instructions and dateofsurgeryareESSENTIAL) (Ifpost-fracture:Dateof fractureand mobilisinginstructions are ESSENTIAL)

Theappropriatecourseoftreatment forpost-operativeandpost-fracturepatientscannotbecarriedoutwithoutthisinformation)

PLEASETICK THEBOXESTHAT BEST DESCRIBESTHISPATIENT:

Completionofthissectionisessential inordertotriagepatientsontoanappropriateclinicalpathwayandensurethattheyareseenina timelymanner

U30 NON-SPINALSURGERY ORA FRACTUREINTHE LAST12 WEEKS?

U SPINALSURGERY ORA FRACTUREINTHELAST12 WEEKS? U INJURY/TRAUMAINTHELAST6 WEEKS
U ACUTELY OFFWORK (LESSTHAN6 WEEKS)DUETOTHISPROBLEM
U PATIENTISAREGISTEREDCARERAND THESYMPTOMS AREAFFECTINGTHEIRCARINGCAPABILITY U CORTICOSTEROIDINJECTIONINTHE LAST2 WEEKS
U / DIAGNOSISBY PAINCLINIC OFCHRONIC REGIONAL PAIN SYNROME (CRPS)
WHCP INCONTINENCE
OR PELVICORGANPROLAPSE / P PREGNANCY RELATED PAIN AND≥34/40 WH(P)BACK PREGNANCY RELATEDBACK PAIN WH(P)SPD PREGNANCY RELATEDPELVIC PAIN /40 EDD: _/ / {INTERPRETER=1:1}
PTA REQUIRESEQUIPMENT PROVISIONONLY(SPLINT,STICKORCRUTCHES)
R NONE OFTHEABOVE
DOESTHEPATIENT REQUIREANAPPOINTMENT WITHIN:
5 WORKINGDAYS? YES NO IFYES PLEASEINDICATEREASON:
OTHER SPECIFIC TIME(E.GPOST-SURGERY?? YES NO IFYES PLEASESTATETIMEFRAME:
PLEASENOTE:PATIENTSWHOHAVEHAD UNSUCCESSFULPHYSIOTHERAPY FOR THE SAME CONDITIONWITH NOSIGNIFICANT CHANGEINTHEIR CIRCUMSTANCES AREUNLIKELY TOBENEFIT FROMRE-REFERRAL. PLEASE CONSIDER REFERRALTOPAINCLINIC,PAINMANAGEMENT (COPE)OR ORTHOPAEDICS
Asignificantnumberofreferralstophysiotherapyareforpatientswhohavehadunsuccessfultreatmentinthepastandareunlikelyto benefitfromfurtherphysiotherapy.Referraltoanotherserviceis likelytobe moreappropriate
PleasereturnthisreferralformtotheSutton Adult ReferralCentre:
Email: Fax:0208 661 3910 Telephone:0208 661 3908

OUTPATIENTANDWOMEN’SHEALTHPHYSIOTHERAPY REFERRALFORMGUIDANCE

The OutpatientPhysiotherapyServiceprovideshigh-quality evidence-basedmusculoskeletalphysiotherapyassessmentand treatment ina clinic-basedsettingtopatients registeredwithSuttonand Merton GPs. Healthpromotion,self-managementand fullparticipationin treatmentareall fundamentalcomponents ofthe OutpatientPhysiotherapyService.

Objectivesof the service

1. To providean efficientassessmentandadvice serviceto patientswitha musculoskeletalproblem.

2. Toadvise on self-management of long-termconditionsanddegenerativediseasessuchasosteoarthritis,and toworkwithin

care pathways tomaximisepatients’independence.

3. To progress rehabilitation of patientsfollowingorthopaedic surgery orintervention,e.g. jointreplacement,spinal surgery,and post-fracture.

Inclusion criteria

• 16 yearsand over

• Registeredwitha Suttonor MertonGP

Exclusion criteria

• Houseboundpatients

• Where serious pathology is suspected

• Post-operative patientswho donothavea copy oftheir operation notes

Beforemakinga referralpleaseconsiderwhetheranalternativetherapyserviceismoreappropriate. Hoverover the servicesbelow to follow the link to ourwebsite:

PatientNeed / Service Required
Multidisciplinary rehabilitationand care in thecommunity for peoplewithneurological
conditions / CommunityNeurotherapyTeam
Short-termrehabilitationfor patientsin bedded units prior todischarge back to their own
home / Community RehabilitationTeam
Patientswhoare65 yearsor overwho have hada fall,havea fearof fallingorareat risk of
falling / FallsPreventionService
Non-urgentdiagnosis ofmusculoskeletaldisorderswhereseriouspathology isnotsuspected andappropriateprimary careinterventions havebeen undertaken / MusculoskeletalCentre
Assessmentand rehabilitationofa physical/ medical condition whichaffects functional
ability / OlderPeople’sAssessmentand
RehabilitationService(OPARS)
Operable conditions ofthe feetsuchashallux valgus, hallux rigidus, osteoarthritis,soft-tissue lesions (neuroma,cysts, ganglion,etc),toe deformitiesormetatarsalgia / PodiatricSurgery
Preventionof unnecessary patientadmission / Rapid Response Team