Self-referral for iMSK Physiotherapy

Self-referral is not appropriate for patients with the following symptoms. If you have experienced any of the following DO NOT FILL IN THIS FORM, please consult your GP for a referral. For symptoms 1 and 2 seek urgent medical advice. 	
1. Unexplained bladder or bowel problems	2. Numbness or tingling around back passage or genitals	3. Pins and needles or numbness in both arms or both legs	4. Pain at night that persists despite changing your position	
5. Fever or night sweats	6. Unexplained weight loss	7. Unsteady on feet	8. On current treatment for Cancer	

Instructions
• You must be 16 years old or over to refer to this service. 
• You should be seeking help for a musculoskeletal (bone, joint or muscle) problem such as back pain, arthritis or a sprain. 
• Referral following orthopaedic surgery must be from the Orthopaedic team.
• You must have a GP registered within North Cumbria area to refer yourself through to this service. 
• If you have multiple area of concern please complete separate self-referral forms for each. 
• Please note that self-referral is not appropriate for patients with any of the 8 symptoms on the top of your referral form.

Please complete the form as fully as possible; the more information that we are given, the easier it is for us to direct people to the most appropriate service. 
Once completed email to: ncm-tr.ncic-imsk-referrals@nhs.net or see below for postal address.
iMSK telephone number: 0333 014 2876

Today’s date 			
NAME: 

ADDRESS: 

DATE OF BIRTH: 

GP SURGERY: 

PHONE NUMBER:                          Consent for contact           
Home:                                                                 
Mobile:                                                               
Email address:                                                   
If required do we have consent to view your medical records?  Yes   	No    

Please state whether you have any information or communication need i.e. hard of hearing, interpreter needed:
_______________________________________________________________________________

About your problem
Please tell us why you need to be seen and which area of your body is affected

How long have you had your problem? ____________________________________________________________ 

Have you already seen someone about this problem?	Yes   	No   
Please tell us who: GP/ Physiotherapist/ First Contact Physiotherapist/ Advanced Nurse Practitioner / Other __________________________________________________________________________________

Has your problem changed?	No change 	Worse   	Better   
Please give us other information as to how you feel this has changed: __________________________________________________________________________________

Have you had to stop work because of this problem?
	Yes   No   Retired   Unemployed	  N/A	   

Are you unable to provide care for a dependent because of this problem?
Yes   No   N/A    

About You
Please list any medical conditions you have- i.e. heart conditions, high blood pressure, diabetes, previous cancer etc._______________________________________________________________ ________________________________________________________________________________

Pain Relief?
Over the counter painkillers can be helpful. A pharmacist will be able to advise you, if symptoms worsen you may need to contact your GP. 

What can I do for myself in the meantime?
Resting for more than a day or so does not help and may prolong pain and disability. You may need to modify your activities, but returning to normal is beneficial to your recovery. Changing your position or activity frequently through the day will help to prevent and reduce stiffness. Try to build up your general activity gradually.  Further guidance is available at: www.versusarthritis.org and https://www.nhs.uk.

What happens next?
Complete the entire form (remember your name) and email it to ncm-tr.ncic-imsk-referrals@nhs.net. Once received your referral will be reviewed by a physiotherapist and you will be contacted in due course to arrange an appointment.  If you prefer you can hand your completed form in to your local Physiotherapy department or send via the post (addresses below).