Pelvic Health Self-Referral Form :: Chesterfield Royal Hospital

About the person wanting physiotherapy

Please do not continue with this form and contact your GP 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 due to weakness (not pain)

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 (specifically, unable to urinate or bowel incontinence)
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. For further information, please read our Cauda Equina Information Card:

Please confirm that you have read and understood the information above Required

I confirm that I have read and understood the above

Patient Details

First name

Surname

NHS Number (if known). You can find this on the NHS app. Required

This can be found on any letter from the NHS like a prescription or appointment letter. You can also use the following link: https://www.nhs.uk/nhs-services/online-services/find-nhs-number/

Date of Birth Required

Address Required

Address 1

Address 2

City

Country

County

Postal Code

GP Details

Your GP details Required

Contact Details

Please make sure the contact details given are accurate as we will be relying on these to get in touch about arranging an appointment or to find out more information.

Preferred Tel No(type): Required

Preferred Tel No: Required

Second Contact No(type): Required

Second Contact No Required

Email address

Please note this may be used by a physiotherapist to send information relating to your treatment.

Reason For Referral

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

If other, please provide details

Are you pregnant?

Is this your first pregnancy?

Yes

How many weeks pregnant are you?

Have you experienced this problem in a previous pregnancy?

Yes

If yes, did you have any physiotherapy treatment?

Yes

If you recently had a baby:

Type of delivery (select all that apply)

Planned Caesarean section

Unplanned Caesarean section

Vaginal Delivery

Episiotomy (cut)

Forceps

Ventouse

Perineal tear

Baby’s weight

If you are experiencing pregnancy-related or postnatal back/pelvic girdle/hip pain, please complete all of the following questions:

Where is your pain? (select all that apply)

Back

Pelvis

Hip

Legs

If the pain is in your legs, how far down does the pain go?

Do you have any pins and needles or numbness?

Yes

If yes, please state where

Any sudden changes in bowel or bladder habits? (specifically, unable to urinate or bowel incontinence)

Yes

Please provide details of any other health problems or problems related to your pregnancy?

Please provide any other details you think are relevant

I agree to the privacy policy

Pelvic Health Self-Referral Form