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Physiotherapy self-referral

Physiotherapy self-referralTom Gamwell2024-07-09T10:53:11+00:00

Pregnancy and after delivery physiotherapy

"*(Required)" indicates required fields

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If you have any vaginal bleeding or fluid loss, reduced baby movements or your baby is not moving as normal, please contact labour line on 0300 369 0388

The Specialist Pelvic Health Physiotherapy Team can treat Pregnancy-related and after delivery back pain, pelvic pain, hand numbness/pins and needles, postnatal separation of the tummy muscles and pelvic floor problems such as bladder and bowel leaking, feeling of vaginal prolapse such as bulging and heaviness, and pelvic floor muscle weakness.

Personal Details

DD slash MM slash YYYY
Find your NHS number
At which hospital would you prefer to receive any physiotherapy appointments, if needed?*(Required)
Your Address*(Required)
Do you have a telephone number?*(Required)
May we leave a voicemail?*(Required)
Are you happy to be contacted by email?
Select "Yes" if you are happy for us to contact you via email OR if you would like a copy of this form sent to your email once submitted.
Would you like a copy of this completed form sent to your email?
Is someone helping you fill in this form?
Have you attended the physio antenatal back group previously?
This may have been a virtual (online) or in person session led by a NHS physiotherapy team member.
Would you like to attend a physio antenatal back group?
Are you Antenatal or postnatal?
Are you a health professional filling in this form?

If you are a member of staff referring on behalf of a patient, please give us the following details:

Antenatal

DD slash MM slash YYYY
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Please tick the symptoms you have:
Where are you booked to give birth?
Type of care?

Postnatal

DD slash MM slash YYYY
Where did you give birth?

What sort of birth did you have?
Did you experience the following
What type of tear

Symptoms

If you have any vaginal bleeding or fluid loss, reduced baby movements or your baby is not moving as normal, please contact labour line on 0300 369 0388

Within this section, we ask you questions regarding your symptoms and pain. Please be as honest as possible so we can get you the help you need. Call NHS 111 if you think you need medical help right now. They will direct you to the best place to get help if you cannot contact your GP during the day, or when your GP is closed (out-of-hours). If you are in a life-threatening emergency, call 999.

Are you unable to walk due to pain?*(Required)
Unable to walk due to pain:
Are you unable to care for children due to symptoms?*(Required)
Is your sleep is disrupted by the pain?*(Required)
My sleep is disrupted by the pain:*(Required)
Do you have pain at the front of your pelvis?
The pain at the front of my pelvis:
Do you have lower back pain?
My lower back pain
Has your lower back pain been getting worse in the last 2 weeks?
Do you have leg pain?
Leg pain is pain that is felt below the knee.
My leg pain is:
My leg pain:
Has your leg pain been getting worse in the last 2 weeks?
Do you have hip pain?
My hip pain

Symptoms continued..

Do you have pain in the buttock area?
My buttock pain:
Do you have numbness or tingling in your fingers?
The numbness or tingling in my fingers:
Do you have numbness or tingling in your legs and feet?
The numb or tingling in my legs and feet:
Do you have pain in the ribs or between the shoulder blades?
The pain in the ribs or between the shoulder blades:
Do you have any of the following pelvic floor, bladder or bowel issues?*(Required)
Have you noticed any loss of feeling, or numbness in or around back passage or buttocks or pins and needles between upper thighs and genitals?*(Required)
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Are your symptoms…? (Please tick as appropriate)

Other useful information

When you submit the form it will go to the Physio department that you chose at the top of the form
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Translations are provided by Google translate, some of the medical terms used may not translate well into a foreign language. Please always seek guidance from your Midwife for clarity.
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