CLMW: Physiotherapy self-referral

CLMW self referral form

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

Please note: This referral option is not available if your referral is regarding a neurological, paediatric, respiratory, obstetric or gynaecological condition or you have a fracture or infection. Should you have one of these other conditions, please contact your GP.

Our team of experts will assess your referral to ensure you are on the most suitable treatment journey for your injury or condition – whether that’s via a face to face appointment, telephone assessment, in a group class setting or with one of our Extended Scope Practitioners for a specialist assessment.

If you are considering physiotherapy as a treatment option for your current symptoms, we recommend first visiting the NHS physiotherapy page. 

Here you will find an overview of what physiotherapy is and when it can be used to help people with bone, joint and soft tissue complaints. You will also find some useful self-care advice that may assist in your recovery without the need to see a physiotherapist.

If you would like to self-refer to physiotherapy please complete the below form or speak with our customer service team on 01772 520900.

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.

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?
Are you currently or have you previously received treatment for this condition?
Do you have any other medical history we should be aware of?
Do you currently have any of the following symptoms?
Is your referral for neck pain?
Are you experiencing any of the following symptoms?
Is your referral for low back symptoms?
If yes, please complete below (these are mandatory for low back pain referrals)
Are you experiencing any of the following symptoms?

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.