Self Referral to Physiotherapy

Please complete all sections of this form and return it to your GP reception desk or to The Physiotherapy Department, Wigton Community Hospital, Cross Lane, Wigton, CA7 9DD ensuring that your name, full address and date of birth are on the top. Please note – incomplete forms may not be processed.

First Name Surname
(please put full name and not just initials)
Address (Including postcode)
Date of Birth / / Date of Referral / /
Phone Number (Home) OK to leave message Yes  No 
Phone Number (Mobile) OK to leave message Yes  No 
Phone Number (Work) OK to leave message Yes  No 
GP Name and Practice –
  1. Please give a brief description of why you need a physiotherapy assessment (include area of body affected)

______

______

  1. How long have you had this problem? ______
  1. Has this problem previously been treated with physiotherapy Yes No
  1. Are the symptoms worsening? Yes No 

(If yes, please give details)

  1. Are you able to carry out normal activities? Yes No
  1. Are you off work/unable to care for a dependent because of this problem Yes No Not applicable
  1. Please give details of any other treatment you have received for these symptoms ______

______

______

  1. Have you had any sudden weight loss without trying? Yes No 
  1. Have you had any other symptoms such as numbness, tingling or muscle weakness? Yes No

(If yes please give details)

  1. If you have back and leg pain, have you developed problems with your bladder or bowel?Yes  No  Not applicable
  1. Please list any current or past medical conditions i.e. heart conditions, high blood pressure, arthritis etc______

______

______

  1. Please list any medications your are currently taking ______

______

______

Do you need physiotherapy?

Back problems?

Stiff joints?

Muscle injuries?

Strains or sprains?

We are trying out a new way for you to get an appointment to see a musculoskeletal

Physiotherapist at Wigton Community Hospital.

If you wish to access the service in this way, you are over 16 years of age and registered with the

following GP practices

Aspatria

Caldbeck

Dalston

Kirkbride

Silloth

Wigton

Please complete a self-referral form, available from your GP and leave with the Reception staff or

send to the Physiotherapy Department, Wigton Community Hospital, Cross Lane, Wigton CA7 9DD.

This self referral system does not necessarily mean you will receive immediate treatment.

Depending on the nature of your condition and the number of referrals received,

you may be placed on a waiting list for a physiotherapy appointment.

You can access advice about various conditions on the local

Cumbria Partnership NHS Foundation Trust website

Certain conditions may be better treated by other specialist services, for example neurological conditions.

In this instance you should discuss your condition and options available with your GP.

Under 16’s require referral by their GP.