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Therapy Self Referral/Preassessment Form
Name: Date Of Birth:

Please complete this form and click the submit button at the bottom of the form once you have done this. Your form will be automatically emailed to the appropriate department.

Please tick the relevant boxes where appropriate and complete all of the form.

At your first appointment, the clinician will ask you some additional questions.

GP Details GP Name:
Surgery:
Your Details Home Telephone: Work: Mobile:
Your Address:
Your Email Address: Confirm Your Email Address:
If you are female are you pregnant?

What is the problem that you are seeking help for?

How long have you had the problem for ?

What is your occupation ?

Are you able to work dispite your current problem ?

List any activities / sports / hobbies that you have difficulty doing in daily life due to this problem ?

Does it affect your sleep ?

Please list all the medication that you are taking, including painkillers

Have you ever taken steroid tablets ?

What do you feel is causing your symptoms ?

What do you hope to achieve from attending this appointment ?

Have you had any X-rays, scans or other test done for this problem ?

Pain, Numbness, and Pins & Needles Location Chart Please click on the location where you are experiencing either pain, numbness, or pins & needles on the body chart below.

Have you ever been diagnosed or had any problems with the following ?
Heart Disease

Lung Disease

Blood pressure

Epilepsy

Stroke

TB

Rheumatoid arthritis

Cancer

Diabetes

Fevers / night sweats

Thyroid problems

Osteoporosis

Please list any other health problems, major accidents or operations :

Have you had any falls in the last 12 months ?

Current Height : Current Weight :

Have you had any unexplained weight loss recently?

Do you smoke?

How much alcohol / number of units do you consume per week?

Do you participate in regular exercise?

Would you like information about local exercise groups / activities ?

Please indicate whether you would like an

Name of the person completing the form

Is your referral for Back pain ?

Referral Failed To Submit

Please enter a valid entry in the highlighted fields.