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I can confirm I have read the checklist above and that I meet the referral criteria(Required)

We are unable to accept your referral

Unfortunately this service is not appropriate for you. Please refer to the 'Other services that can help you' section of our webpage for further information.

At which site would you like to attend your appointments?

Which GP practice are you registered with?

About you

You can look up your NHS number here: www.nhs.uk/nhs-services/online-services/find-nhs-number
I would describe my ethnic origin as:(Required)
Your Name(Required)
Date of birth(Required)
Please state if retired and/or on disability benefit.
Do you require an interpreter?(Required)

Your contact details

Your Address(Required)
Are you a Gloucestershire Health and Care NHS FT staff member?(Required)
Did your GP / healthcare professional prompt you to fill in this form?(Required)
Please specify(Required)
Have you attended physio before for the same problem?(Required)
How long ago?

Where is your main muscular/joint problem/condition?

Please check the referral information on our website to determine what constitutes an appropriate or inappropriate referral to our service. When filling in this self-referral form it will only allow you to indicate ONE main area of pain or condition. IF YOU HAVE A SECOND PROBLEM, A FURTHER REFERRAL FORM MUST BE COMPLETED.
Possible diagnosis/symptoms. Please record symptoms such as pins and needles and numbness. Have you had any X-rays/scans or other investigations? Please specify if you have any specific medical conditions.
Are you pregnant or have you given birth in the last 2 years?(Required)
Did you attend a Minor Injury Unit or A&E?
0 = no pain 10 = extreme pain
0 = not restricted 10 = extremely restricted
Are your symptoms getting worse?
Does your problem wake you up at night?
If you are woken by this pain, does it prevent you from getting back to sleep?
Are you off sick from work due to this problem?
Are you a registered carer whose role is currently affected by your symptoms?
Would you consider a one-off advice and education / exercise prescription service?
Would you potentially be able to attend an appointment at short notice?
You should receive confirmation of your submission via e-mail. If you do not receive a confirmation, please check your spam and junk folders.