"*" indicates required fields Step 1 of 2 50% The Staff Physiotherapy Service 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.I can confirm I have read the checklist above and that I meet the referral criteria * REQUIRED Yes No We are unable to accept your referralUnfortunately this service is not appropriate for you. Please refer to the Other services that can help you section of our webpage for further information. Your physiotherapy records and this referral will be held within the Occupational Health software called G2. Your records will ONLY be accessible to the Occupational Health team and your treating physiotherapist.I am happy for my records and this referral to be held on the Occupational Health G2 system * REQUIRED Yes No Please could you contact Working Well on 0300 421 4455 to discuss how we can hold your records securely, but in a manner you are happy with. Please indicate your preferred clinic from the dropdown menu below: * REQUIREDpreferred clinicStroud Therapy Department, Kings StreetWorking Well at Rikenel, GloucesterCirencester HospitalWhere is your place of work? * REQUIREDWhat is your job role? * REQUIREDAre you currently absent from work as a result of this problem? * REQUIRED Yes No 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 DetailsYour name * REQUIREDDate of Birth * REQUIRED DD slash MM slash YYYY Ethnicity * REQUIRED--- Please Select ---Asian or Asian BritishBlackMixed ethnic backgroundWhiteOther ethnic groupI Do not wish to sayAddress Street Address Address Line 2 Town or city Postal code Your GHC email address * REQUIRED Your mobile number * REQUIREDHome PhonePreferred Method of Contact * REQUIRED Mobile Phone Home Phone Name of GP Surgery * REQUIREDGP's NameNHS numberYou can look up your NHS number at Find your NHS number Do you require an interpreter? Yes No Which language?Are you pregnant? Yes No Not applicable Presenting Problem DetailsBrief description of the problem you are referring yourself to Physiotherapy for and the body part affected. * REQUIREDHow long have you had the problem for? * REQUIRED 1 week less than 6 weeks more than 6 weeks more than 3 months On average, how painful is your problem (0-10)?0 = no pain / 10 = extreme painPlease choose a number012345678910On average, how restricted are you in carrying out your daily activities?0 = not restricted / 10 = extremely restrictedPlease choose a number012345678910Is the problem getting? * REQUIRED Better Worse Staying the same Are you currently absent from work because of this problem? * REQUIRED Yes No Not Applicable Does it wake you from your sleep * REQUIRED Yes No Sometimes Are you a registered carer? Yes No Is your caring role currently affected by your symptoms? Yes No Have you attended physiotherapy for this condition before? * REQUIRED Less than 1 year More than 1 year No Is this referral for back pain and/or sciatica? * REQUIRED Yes No 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 Disagree Agree 2. I have had pain in the shoulder or neck at some time in the last 2 weeks Disagree Agree 3. I have only walked short distances because of my back pain Disagree Agree 4. In the last 2 weeks, I have dressed more slowly than usual because of the back pain Disagree Agree 5. It’s not really safe for a person with a condition like mine to be physically active Disagree Agree 6. Worrying thoughts have been going through my mind a lot of the time Disagree Agree 7. I feel that my back pain is terrible and it’s is never going to get any better Disagree Agree 8. In general I have not enjoyed all the things I used to enjoy Disagree Agree 9. Overall, how bothersome has your back pain been in the last 2 weeks? Not at all Slightly Moderately Very much Extremely Would you consider a one-off advice and education / exercise prescription service? Yes No Would you potentially be able to attend an appointment at short notice? Yes No CAPTCHA