YOUR PHYSIO - Refer yourself

YOUR PHYSIO

Refer yourself

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You can self refer for physiotherapy treatment if:

-You are over the age of 17+

-You are registered with a Vale of York CCG including Pocklington

-You have a musculoskeletal pain problem (self referral isn't available for mobility rehabilitation, neurological problems, or continence rehabilitation)

If you have a personal history of cancer please do not use the self referral form, you should see your GP in the first instance

Patients registered with an East Riding GP please be aware that from 1^st January 2020 access to self referral forms will be available on www.chcpmsk.org.uk

A PDF copy for Vale of York GP Practices to print is available here .

Refer Yourself

Are you in the right place?

Date of birth

Day:

Month:

Year:

GP Surgery

Please be aware that if you are not registered with the GP practice you select then we may be unable to process this referral.

You are referring to the York & Selby MSK Service. As you are registered to Pocklington Group Practice, you can either by seen locally in the GP practice or by a member of the Physiotherapy team in the York region. Please select your preferred area:

Continue

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

Yes

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

Yes

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

Yes

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

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

Yes

Do you have a history of cancer?

Yes

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

Yes

[REMOVED]Did you have spinal cancer?

Yes

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

Continue

Are you experiencing altered sensation or weakness in your limbs / feel uncoordinated / losing your mobility?

Yes

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

Yes

Select body region

If you have back and leg pain (sciatica) please click on the back to ensure the referral is processed correctly.

If you wish to refer yourself for multiple problems, you will be given the option to do this at the end of this form. Please select one problem area and answer the questions relating to the selected area.

Front of body

We are unable to process head or chest pain via self-referral. If you have head or chest pain we would advise that you contact your GP to discuss these symptoms. If your GP feels it is appropriate, they can refer direct to physiotherapy.

Back of body

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

Yes

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

Yes

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

Yes

Do you have widespread body pains?

Yes

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

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

Yes

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

Yes

Do you have persistent swelling of one joint or more?

Yes

If you squeeze the joints are they painful?

Yes

Do you experience night pain?

Yes

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 previously for this condition?

Yes

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

Yes

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

Yes

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

Yes

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

Yes

Do you have any other important health problems?

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Please provide details of the physiotherapy you have had

Continue

Did physiotherapy help to improve your symptoms by more than 50% for a sustained period e.g. 3 months?

Yes

Are you a medical veteran or on current active service?

Yes

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

Yes

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

Yes

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

Yes

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

Yes

Did your back pain develop gradually?

Yes

Does your back pain improve with movement?

Yes

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

Yes

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

Yes

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

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

Yes

I have only walked short distances because of my back pain

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Do you have a pregnancy related problem?

Yes

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

Yes

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

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

Yes

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

Continue

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

Yes

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?

Continue

Your details

Date of birth

Address

Telephone

Smoking status

BMI

Height

Feet:

Inches:

Height

Unit:

Weight

Stones:

Pounds:

Weight:

Unit:

What are your expectations for physiotherapy?

Do you have any special requirements which we need to know about prior to your appointment? e.g. you require an interpreter, you require sign language support, you have mobility issues etc.

Submit referral

Please wait while we submit your referral

Start a new referral

Send me a confirmation email

Forename

Surname

Please give a brief description of your problem - Where is the pain? Are there other symptoms such as pins and needles or numbness? How did it start?

NHS/Hospital number (if known)

Do you have any medical conditions?

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. 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 a serious condition called cauda equina syndrome. This can lead to permanent damage and disability. We are therefore unable to process this referral and would recommend you immediately call 111 to discuss your symptoms.

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.

If you would like email confirmation that your referral has been received, please enter your email and press submit.

Email address

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?

Continue

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?

Continue

Please be aware that pregnancy related problems are usually managed by the Women’s Health Physiotherapy Team. Pregnant patients or patients who have recently given birth (less than 3 months ago) are managed by the Women’s Health team. This team does not accept self-referrals and you would require a direct referral from your GP or Midwife. Please provide us with information about your problem. One of the team will review this information and write to you to inform you if the referral is rejected.

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

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?

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

Covid-19 Update

You can self refer for physiotherapy treatment if:

-You are over the age of 17+

-You are registered with a Vale of York CCG including Pocklington

-You have a musculoskeletal pain problem (self referral isn't available for mobility rehabilitation, neurological problems, or continence rehabilitation)

If you have a personal history of cancer please do not use the self referral form, you should see your GP in the first instance

Are you in the right place?

Date of birth

GP Surgery

You are referring to the York & Selby MSK Service. As you are registered to Pocklington Group Practice, you can either by seen locally in the GP practice or by a member of the Physiotherapy team in the York region. Please select your preferred area:

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

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

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

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.

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

Do you have a history of cancer?

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

[REMOVED]Did you have spinal cancer?

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

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

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

Do you have mid back (thoracic) pain?

Are you experiencing altered sensation or weakness in your limbs / feel uncoordinated / losing your mobility?

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

Select body region

Front of body

Back of body

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

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

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

Do you have widespread body pains?

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

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

Do you have persistent swelling of one joint or more?

If you squeeze the joints are they painful?

Do you experience night pain?

Select the option that most closely matches your symptoms

Have you had physiotherapy previously for this condition?

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

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

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

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

Do you have any other important health problems?

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

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

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

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

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

Please provide details of the physiotherapy you have had

Did physiotherapy help to improve your symptoms by more than 50% for a sustained period e.g. 3 months?

Are you a medical veteran or on current active service?

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

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

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

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

Did your back pain develop gradually?

Does your back pain improve with movement?

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

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

Have you had symptoms for:

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

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

I have only walked short distances because of my back pain

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

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

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

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

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

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

Do you have a pregnancy related problem?

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

When did you see your GP Practice about this problem?

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

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

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

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

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?

Your details

Date of birth