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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.

For queries surrounding any of these please contact 01482 247111

Your Information

I am filling the form on behalf of another person

Without consent from the patient we can only share limited information with people other than the patient unless it is in the patients best interests.

Is the patient aware of the referral?

Without consent from the patient we are unable to accept the referral. Please ask the patient to refer themselves via this form or by calling 01377 208300. Alternatively ensure consent is gained from the patient and they are aware of the referral being made on their behalf.

Patient Information

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

Do you give consent to receiving text messages from the service?

How we use your information

Do you give consent to receiving emails from the service?

How we use your information

Do you give consent to share your GP record?

Referral Information

Is this a referral for a fracture or surgery in the last 3 months?

Where do you get your symptoms?

Please draw on the chart where you get your symptoms.

Front facing

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Back facing

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More information about the problem with your back
More information about the problem with your neck
More information about the problem with your shoulder
More information about the problem with your elbow
More information about the problem with your wrist
More information about the problem with your hip
More information about the problem with your knee
More information about the problem with your ankle

Have you had any investigations for this problem?

Please note only record investigations that directly relate to the problem you are reporting today.

Does this fit note (sick note) relate to the referral you are making today?

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

Diabetes

Osteoporosis

Rheumatoid Arthritis

Allergies

Do you smoke?

How many units of alcohol do you drink each week?

Do you require a translator to be provided for your appointment? Please note it is CHCP Policy that a family member or friend cannot be used for translation purposes.

CHCP MSK Physiotherapy can offer advice and treatment via Telephone/Video consultations. Accessing physiotherapy this way is usually quicker and be arranged at a convenient time for you. Please note when choosing this option that all future consultations will be managed via telephone/video too.

Would you like a telephone/video consultation?

Once you have completed the form, your referral will be registered and our admin team will be in contact to arrange your Telehealth appointment as soon as possible.

Please indicate where you would prefer to be seen

As you have choosen to be seen face to face we advise that In some clinical circumstances you may be required to remove items of clothing. If you would like a Chaperone at your appointment then please advise us at the time of booking 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.

Immediate medical advice is available by contacting NHS 111

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

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