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