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Fast Track Physiotherapy is a designated physiotherapy service for all employees of Gloucestershire Health and Care. You can refer yourself at any time if you are experiencing musculoskeletal pain. We aim to speak to you for a telephone assessment between 2 -7 days following your referral.
Are you an employee of Gloucestershire Health and Care NHS FT?
Are you currently absent from work as a result of this problem?
Line managers may request to know about appointment times and attendance which fall within your contracted work hours. Whilst they are entitled to this information, no details of your clinical condition or treatment will be disclosed without your prior permission.

Your Details

Date of Birth * REQUIRED
Address
Preferred Method of Contact * REQUIRED
Do you require an interpreter?
Are you pregnant?

Presenting Problem Details

How long have you had the problem for? * REQUIRED
Is the problem getting? * REQUIRED
Are you currently absent from work because of this problem? * REQUIRED
Does it wake you from your sleep * REQUIRED
Availability for work
Are you the main carer for a family member?
Is your caring role currently affected by your symptoms? 
At which hospital site would you like your appointment?
Have you attended physiotherapy for this condition before? * REQUIRED
Is this referral for back pain and/or sciatica? * REQUIRED

Thinking about the last 2 weeks tick your response to the following questions:

1. My back pain has spread down my leg(s) at some time in the last 2 weeks
2. I have had pain in the shoulder or neck at some time in the last 2 weeks
3. I have only walked short distances because of my back pain
4. In the last 2 weeks, I have dressed more slowly than usual because of the back pain
5. It’s not really safe for a person with a condition like mine to be physically active
6. Worrying thoughts have been going through my mind a lot of the time
7. I feel that my back pain is terrible and it’s is never going to get any better
8. In general I have not enjoyed all the things I used to enjoy
9. Overall, how bothersome has your back pain been in the last 2 weeks?