Self-Referral Form

To self-refer to physiotherapy you must be aged 18 or over and be currently registered with an East Riding GP (excluding Pocklington)  and seeking help with an MUSCULOSKELETAL CONDITION

We do not accept referrals for home visits, walking aids, vertigo, breathing, neurological problems, falls assessments, amputees, urinary incontinence or vaginal prolapse, Bell's Palsy or for the general management of Rheumatologicall conditions such as fibromyalgia.

For children aged  5-17 a referral must be done via your East Riding GP on your behalf.

Patients registered with Pocklington GP practices must self refer to York NHS physiotherapy services via www.yourphysio.org.uk

For queries surrounding any of these please contact 01482 247111

Your Information

Are you registered with an East Riding GP (excluding Pocklington)?

Do you give consent to share your GP record?

Referral Information

Please draw on the chart where you get your symptoms.

Front facing

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Redo
Start again

Back facing

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Start again

Have you had any investigations for this problems?

Please tell us a little more about your general health. Have you ever had any of the following?

Unexplained changes to your bladder & bowel habit including loss of control or sensation

Changes in sexual function, including loss of sensation during intercourse, inability to achieve an erection or ejaculate

Swollen hot joints

Morning joint stiffness lasting more than 30 mins

Severe night pain stopping you from sleeping

Unexplained weight loss

Fever or night sweats

Heart problems

Cancer

Epilepsy

Diabeties

Osteoporosis

Rheumatoid Arthritis

Allergies

Do you smoke?

How many units of alcohol do you drink each week?

CHCP MSK Physiotherapy are now offering physiotherapy advice and treatment via Telephone/Video consultations. Accessing physiotherapy this way is usually quicker and be arranged at a convenient time for you. This may be of benefit for those struggling to attend more traditional clinic appointments or those who are looking to further enhance their social distancing. Please note when choosing this option that all future consultations will be managed via telephone/video too.

If you would prefer to use this service then please tick the box below

Below is a list of our sites, please indicate where you would prefer to be seen

Do you require a translator to be provided for your appointment?

Symptom to Check

Your response to this question could be a sign you may need to be checked urgently.

Please contact 111 to receive additional advice.

We cannot accept a referral if you have this symptom.

To self-refer to physiotherapy you must be 18 or over and be currently registered with an East Riding GP (excluding Pocklington) and seeking help with a MUSCULOSKELTAL CONDITION.

Unfortunately we cannot accept a referral if you are not registered with an East Riding GP.

Patients registered with Pocklington GP practices must self refer to York NHS physiotherapy services via www.yourphysio.org.uk