Get Physiotherapy Service Self Referral Form - Health In Wales

Filling out the Physiotherapy Service Self Referral Form is an essential step for individuals seeking physiotherapy for musculoskeletal issues. This guide provides clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to successfully complete your referral form.

1. Press the ‘Get Form’ button to access the Physiotherapy Service Self Referral Form and open it for editing.
2. Begin by entering your full name in the designated field. It is important to use block capitals for clarity.
3. Select your title from the available options such as Mr, Mrs, Miss, Ms, Dr, or Rev. Ensure this selection corresponds with your identity.
4. Provide your complete address, including the postcode, in the relevant fields. Accuracy is vital to avoid delays in processing your referral.
5. Enter your date of birth by following the specified format, ensuring it is clearly shown.
6. Indicate your sex by selecting M for male or F for female, as applicable.
7. Fill in your contact telephone numbers – home, work, and mobile. Remember to specify if you consent to receive messages on each line by selecting yes or no.
8. Provide the name and practice of your general practitioner (GP) to facilitate communication regarding your referral.
9. Summarize your symptoms or reasons for seeking physiotherapy in the relevant section. Be concise but thorough.
10. Indicate the duration of your problem in days or weeks, as applicable.
11. Describe the onset of your issue, specifying how it started (e.g., injury, gradual development).
12. Clarify whether you experience persistent pain or intermittent pain, and note how frequently the pain occurs.
13. Answer questions regarding factors that increase or reduce your pain, and specify any patterns related to the time of day.
14. Disclose any previous treatment or physiotherapy for this condition alongside relevant details if applicable.
15. Confirm whether you have had any X-rays or tests related to this problem and provide results if available.
16. Indicate any past occurrences of this problem by responding accordingly.
17. If applicable, answer the questions related to joint issues, such as locking or giving way.
18. State whether this issue impacts your work or caregiving responsibilities.
19. List activities you are unable to perform due to this problem.
20. Outline your expectations from the physiotherapy treatment.
21. Indicate any presented symptoms related to urinary or bowel issues, as well as any major health concerns.
22. Complete the section on current medications, highlighting any medications such as steroids or blood thinners.
23. Use the provided images to indicate areas where you experience symptoms, such as pain or numbness.
24. Once all fields are completed, review your form to ensure accuracy and completeness before saving changes, downloading, or printing.

Complete your Physiotherapy Service Self Referral Form online to take the first step towards your recovery.