NEL self-referral

I certify that all information detailed on the attached form is accurate to the best of my knowledge and this information will be shared with the selected GP.

Your details

Title

Forename

Surname

Address

City/Town

Postcode

Telephone number

Alternative contact number

DOB

Gender

Male

Female

Prefer not to say

NHS number

GP name

Registered GP practice

Do you have any particular communication needs?

Yes

If yes, please provide further information:

Do you require an interpreter for your assessment?

Yes

If yes, which language?

Are you happy for us to leave a voicemail?

Yes

Body part affected

If other, please provide more detail:

Brief description of your current symptoms:

How long have your symptoms been present?

Less than 1 week

Less than 6 weeks

More than 6 weeks

More than 3 months

My symptoms are...

Improving

Not changing

Worsening

Have you had treatment for this condition before?

Yes

If yes, please provide further information:

Are you off work due to this problem?

Yes

Identify three activities that your symptoms are affecting:

Do you have any other medical history we should be aware of?

Is your referral for lower back symptoms?

Yes

If yes, do you have any of the following symptoms?

Altered sensation in both legs (i.e. pins and needles or numbness)

Numbness between your legs (genitals and anus)

Loss of bowel control

Urine retention (urgency without passing urine)

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