North Worcestershire Self Referral Form
If you have an outpatient MSK physiotherapy appointment booked, please do NOT attend in person. Please be aware that the MSK service are utilising telephone and video software to enable the physiotherapist to complete a remote assessment. The telephone number will be withheld so please make sure that your phone allows you to receive incoming calls from withheld numbers. If a video call is required, you will need to download the appropriate software (Webex) to your mobile phone/tablet/laptop/PC and ensure that you have a web camera and microphone. In order to send the invite to the video call, we will require an e-mail address. If a video call is not possible, you will still receive a telephone assessment.
For those living in Bromsgrove or Redditch. Please click here if you live in Evesham, Droitwich, Pershore, Malvern, Tenbury, Worcester and Upton.
Before you complete the self-referral form
- Have you been using the advice and tips on the self-help sections for around 8 weeks?
- Are you still feeling pain or discomfort?
- Are you registered with a GP practice in Bromsgrove or Reddtich?
If you have answered yes to all the above then you should complete the below form, providing as much information as possible.
Please enter the following information and press submit once. Once submitted you will receive a read receipt via a no-reply e-mail. Your referral will then be triaged by a physiotherapist. Please note, from triage, there are different options that a physiotherapist may deem appropriate including referral directly into the Joint Pain Education Group; referral for a 1:1 remote consultation with a physiotherapist and referral directly into specialist services (e.g. Functional Restoration). Following any 1:1 remote consultation the physiotherapist may also deem it appropriate to refer you into other services (e.g. Advanced Physiotherapy/Podiatry Practitioner, Functional Restoration) or to one of three treatment groups (The Arm Class, The Leg Class or Back on Track). A physiotherapist may also deem it necessary to see you in clinic face-to-face but this will be discussed in more detail if appropriate. Please note, a risk assessment will still need to be completed to determine if this is possible.”
You can call 01527 488038. Monday - Friday: 8.30am - 16:00 to check the progress of your referral or to cancel an appointment that you no longer require. *Please note that you cannot self-refer by calling this number, please instead complete the self – referral form below.
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‘Cauda Equina Syndrome’, although rare, can cause a permanent change to your bladder and/or bowel function, or foot strength. Cauda equina syndrome is a condition which occurs when the nerves at the base of the spinal cord become squeezed in the spinal canal. This can happen quite suddenly or gradually. It can cause pain in the lower back and/or legs, numbness or weakness in one or both legs, in the buttocks or between the legs (the ‘saddle region’). It can also cause problems with bladder or bowel control and sexual function.
IF you are suffering with low back pain and if you have any changes regarding the following since your pain started;
- Bladder or bowel function (i.e., Increasing difficulty when you try to urinate, increasing difficulty when you try to stop or control your flow of urine, loss of sensation when you pass urine, leaking urine or recent need to use pads, inabilityof knowing when your bladder is either full or empty, inability to stop bowel movement or leaking, loss of sensation when you pass a bowel motion)
- Loss of sensation / tingling around genitals, back passage, buttocks or inner thighs
- Erectile or ejaculation problems or loss of sensation in genitals during sexual intercourse
- Loss of sensation/ tingling or numbness in both legs • Weakness in foot (i.e. floppy foot or inability to lift front of foot when walking)
If YES call NHS 111 or go to A+E IMMEDIATELY
IF you are suffering with constant pain and if you have any of the following;
- History of Cancer
- Unexplained weight loss
- Feeling generally unwell/ fever/ lack of appetite
- Relentless night pain that cannot be relieved by changing position in bed
Please contact with your GP as soon as possible to discuss if other investigations are required rather than self- referring to physiotherapy.
Complete the form below to self refer
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