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Get PHYSIOTHERAPY SELF-REFERRAL FORM

Please give details) Yes when? No On the chart below please mark where you feel you are getting your symptoms eg pain, pins and needles, areas of numbness or areas of weakness. Does the problem involve changes to your bladder or bowel habits? Have you suddenly lost weight without trying? Yes No If you have night pain, is your sleep disturbed? Yes No Are the symptoms worsening? Yes No Yes No N/A (If yes please give details) Pl.

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