"*" indicates required fields Step 1 of 2 50% 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.Are you a staff member of Gloucestershire Health and Care NHS Foundation Trust? * REQUIRED Yes No have you read the information about ‘when to seek urgent medical support’? * REQUIRED Yes No Are you seeking specific physiotherapy treatment for the following conditions/problems? Neurological conditions – e.g. stroke, MS, head or spinal cord injuries, functional neurological disorders. Parkinson’s Respiratory conditions – e.g. asthma, cystic fibrosis, chronic lung conditions, hyperventilation * REQUIRED Yes No Do you require community physiotherapy, or physiotherapy at home? * REQUIRED Yes No Is your main problem related to mobility or balance issues * REQUIRED Yes No Sorry. You cannot complete this formYou must read the urgent medical support information before continuing with this referral Where is your place of work?What is your job role?Are you currently absent from work as a result of this problem? 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 Name * REQUIREDNHS numberYou can look up your NHS number here: www.nhs.uk/nhs-services/online-services/find-nhs-numberDo 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 Is 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 Availability for work Working Unemployed Not Applicable Are you the main carer for a family member? Yes No Is your caring role currently affected by your symptoms? Yes No At which hospital site would you like your appointment? Stroud Therapy Department, Kings Street Cirencester Hospital Working Well at Rikenel, Gloucester 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 CAPTCHA