There are a range of resources available via national charities, the Chartered Society of Physiotherapy, as well as support available locally to help you keep healthy and active.

Please do not continue with this form and contact your GP if:​

  • You are seeking treatment for a diagnosed heart, lung, or neurological condition​
  • You require therapy at home ​

Or if:​

  • ​You are losing weight for no reason.​
  • ​You are feeling generally unwell or feverish.​
  • ​You have recently become unsteady on your feet​
  • ​You have suddenly noticed weakness in any of your muscles, for example you struggle to lift your foot off the floor.​

Please do not continue with this form and call NHS 111 if: ​

You have recently or suddenly developed lower back pain and/or leg pain AND have any of the following symptoms: ​

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

These symptoms are a possible sign of Cauda Equina Syndrome. This is a condition that requires urgent medical attention. 

 

Please see the following link for further information about Cauda Equina Syndrome: https://www.chesterfieldroyal.nhs.uk/all-services-and-wards/physiotherapy-services/musculoskeletal-and-rheumatology-services/cauda-equina

This referral process is for Adult (over 18's) only

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Patient Details:

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DOB: Required
Europe/London
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Click on this link to find your NHS No: https://www.nhs.uk/nhs-services/online-services/find-nhs-number/

Address: Required
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If your GP is not listed and you wish to have Physiotherapy treatment at Chesterfield Royal you will need to speak with your GP direct to ask them to refer you

Reason for Referral:

We want to book the most appropriate appointment to meet your needs as a patient.  To help us do this, we need you or your representative to answer the following questions:

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Are your symptoms worsening? Required
Are you off work/unable to care for a dependant because of this problem? Required
Do you have any pins and needles? Required
Do you have any numbness? Required
Do you have muscle weakness? Required
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