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Self Referral into MSK Physiotherapy Service

If you wish to attend either Gloucester Royal Hospital or Cheltenham General Hospital Physiotherapy Departments please click on this link

Patient Details

Title*
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First Name*
Please type your first name.

Last Name*
Please type your last name.

Date of Birth*
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Ethnicity*
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If you have selected ‘other’ please specify below:
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Occupation
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Address Line 1*
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Address Line 2
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Address Line 3
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Postcode*
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GP Surgery*
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GP's Name*
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Who prompted you to complete this electronic self-referral?*
Please select an option from the check boxes

***Gloucestershire Care Services Staff Section Only***

Are you an employee of Gloucestershire Care Services?
Please select an option from the list

What is your occupation?
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Where is your place of work?
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Are you currently absent from work as a result of this problem?
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Patient Contact Details

Mobile Phone
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Home Phone
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Work Phone
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E-mail*
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Preferred Method of Contact*
Please check at least one.



Please note that the Adult Physio Team cannot arrange appointments via email

Presenting Problem Details

Brief description of the problem you are referring yourself to Physiotherapy for and the body part affected.*
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How long have you had the problem for? *

Please select at least one

Is the problem getting?*
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Can you identify up to 3 activities affected by this problem

1.
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2.
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3.
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Are you able to work / continue with your home activities. *
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Does it wake you from your sleep*
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Availability for work
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Would you like an appointment, or would you like to speak to a Physiotherapist over the telephone?*
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Have you attended physiotherapy for this condition before?*
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Is this referral for back pain?*
Please select at least one