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CLMW: Physiotherapy self-referral

CLMW self referral form

Welcome to the Central Lancashire Moving Well physiotherapy self-referral form.

Important notice

While self-referral to physiotherapy is appropriate for the majority of people, there are some exceptions where we would advise you to seek alternative medical assessment first. 

Please do not complete this referral and call NHS 111 or immediately attend your local A&E if you have recently or suddenly developed, with the onset of low back pain and/or leg pain:

  • A change in your bladder function or bowel control
  • Altered sensation around your genitals or back passage
  • Loss of sexual function

Please do not complete this referral and make an appointment with your GP if you have any of the following (your GP will need to complete a referral on your behalf):

  • History of cancer, or being actively treated for cancer
  • Unexplained weight loss
  • Pain and/or altered sensation in both arms and/or both legs
  • Have become unsteady on your feet
  • You’ve noticed changes in your vision, speech or swallowing 
  • Have become feverish or are feeling generally unwell

Please note: This referral option is not available if your referral is regarding a neurological, paediatric, respiratory, obstetric or gynaecological condition. This referral route is also not available if you have a fracture or have had surgery to the affected area in the past six months or have a suspected infection. Should you have any of these other conditions, please contact your GP.

To use this service you must be a patient registered with a Preston, Chorley or South Ribble GP practice and be 16 years of age or older. If you need treatment for more than one body part, you will need to complete a separate referral for each. 

Are you currently or have you previously received treatment for this condition?

Your details

Sex
If known
I.e. hearing loss / speech difficulties
If so, please inform us of required language
What is your preferred method of contact?
Would you like to receive appointment reminder texts?
Are you happy for us to leave a voicemail?
Are you currently under, or have you recently been seen by, the Lancashire Care Foundation Trust Rheumatology Service?
Are you currently under, or have you recently been seen by, the Lancashire Care Foundation Trust Community Pain Service?

Reason for referral

Body part affected
How long have your symptoms been present?
My symptoms are:
Pain level today
0 being pain free and 10 being highest possible pain
If you are working, can you complete your normal duties?
Have you had any scans or investigations for this condition?
Which of the following scans or investigations have you had for this condition?
Do you have any other medical history we should be aware of?

The Keele STarT Back Screening Tool

My back pain has spread down my leg(s) at some time in the last 2 weeks
I have had pain in the shoulder or neck at some time in the last 2 weeks
I have only walked short distances because of my back pain
In the last 2 weeks, I have dressed more slowly than usual because of back pain
It's not really safe for a person with a condition like mine to be physically active
Worrying thoughts have been going through my mind a lot of the time
I feel that my back pain is terrible and it's never going to get any better
In general I have not enjoyed all the things I used to enjoy
Overall, how bothersome has your back pain been in the last 2 weeks?

For more information on how Central Lancashire Moving Well process or protect your data, click here.

I can confirm that the above information is factual to the best of my knowledge