This form is for patients wishing to self-refer to MSK Physiotherapy. Please do not use this form if the reason for your referral is linked to a current pregnancy as the service will require a direct referral from your antenatal clinician.

MSK Physiotherapy Referral form

Q1 - Name(Required)
DD slash MM slash YYYY
Q5 - Address(Required)
Preferred method of contact
Q9 - Interpreter required(Required)
Q12 - Main body parts affected(Required)

Q14 - Was the injury caused by a fall, direct impact or during sports?
Q19- Are your symptoms:(Required)
Q20 - Are you off work due to your problem?(Required)
Q22 - Do you have any of the following symptoms:(Required)
Q23 - Do you have any of the following health conditions (please tick those that apply)
Q25 - Have you been treated by the physiotherapy department for the same condition in the past six months?(Required)
Q26 - Do you consent to MSK Physiotherapy accessing your GP medical record ahead of your appointment(Required)
Q27 - Do you consent to an answerphone message being left on the number you have provided?(Required)
Important information

If you have BACK PAIN and any of the following symptoms which are NEW or WORSENING please DO NOT submit this form but phone 111 (NHS Direct) as a matter of urgency:

  • A loss of sensation when you pass urine
  • Increasing difficulty or inability to urinate or leaking of urine
  • Numbness around back passage/buttocks
  • Numbness/pain/weakness in both legs
  • Unable to achieve an erection/loss of sensation during intercourse.

Q28 - If you have BACK PAIN but none of the above symptoms please complete the following thinking about the last 2 weeks:

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