Refer Yourself

EXCLUSION CRITERIA……

Please note that HealthshareCentralLondon are unable to treat patients who….
…do not have a suspected musculoskeletal condition.
…are under the age of 16 for physical therapies and interface service.
…are not registered with a GP in the commissioning borough (unless a NCA (non contractual agreement) is in place).
…require inpatient care/day-case services beyond simple procedures and outpatient infusion / injection treatments provided by the community MSK service.
…require NHS England Prescribed Specialist Commissioning Services.
…require home visits.

HELP WITH TRAVEL COSTS……

If you are referred to hospital or other NHS premises for NHS specialist treatment or diagnostic tests by your doctor, dentist or other health professional, you may be able to claim a refund of reasonable travel costs under the Healthcare Travel Costs Scheme (HTCS).  
Visit the NHS UK website to find out who is eligible for the scheme and how to make a claim.
HCT(T) Refund claim form - travel costs to receive NHS treatment.

By filling out this form and submitting it you consent to data being transferred via secure email.  
We would be grateful if you could have your NHS number ready when contacting us or using this self-refer page.

 Please ensure you fill out all mandatory fields marked with an asterisk(*).
When you click the Submit button at the end of the form and it does not appear to work please check that you have completed the required fields.  When submitted successfully you should receive a completion message.

DEMOGRAPHIC INFORMATION
Please confirm if you are the patient or if you are completing this form on behalf of someone else*

Please select an option

Please state in what capacity you know the patient
Please state in what capacity you know the patient

First name*
Please enter your first name

Surname*
Please enter your surname

Date of birth*
Please enter your date of birth

**Please use the format DD/MM/YYYY**

What is your gender?

Please select an option

Address 1*
Please enter your address

Address 2
Please enter your address

County
Please enter your county

Post code*
Please enter your post code

Email Address
Please enter a valid email address

If you have provided an email address confirmation of your self-referral will be sent to you when you have successfully submitted the form.
Please check the spam folders within your email if you do not receive a confirmation in your inbox.

Please tick your contact devices*

Please select an option

We may need to contact you to discuss your referral or to arrange an appointment within the service. Please tick your preferred method of contact.*

Please tick one of the options

Landline number*
Please enter your landline number

Can voicemail messages be left on your landline?*

Please select an option

Mobile number*
Please enter your mobile number

Can voicemail messages be left on your mobile?*

Please select an option


GP name*
Please enter a GP name

GP surgery*
Please enter the name of your GP surgery

GP surgery telephone number (if known)
GP surgery telephone number (if known)

Is your GP aware of your self-referral?

Please select an option

NHS Number
Please enter your NHS number

What is your weight? Would you like to use lbs or kg?*

Please select either lbs or kg

What is your height? *
Please select your height from the dropdown menu

What is your current weight in kilograms?*
Please adjust the slider to your weight in kilograms

What is your current weight in pounds?
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What is your ethnicity?*

Please select an option

What ethnicity are you?
Please type your ethnicity in the box

Please enter ethnicity


CURRENT DIFFICULTIES
On what part of your body do you have a problem?*
Please enter what part of your body is affected

How long have you had this complaint?*
Please tell us how long you've had this complaint

Please give a brief description of why you need physiotherapy*
Please briefly explain why you need physiotherapy

Is the problem...*

Please select an option

Are you having difficulties sleeping?*

Please select an option

Have you had any other symptoms such as numbness, tingling, or muscle weakness?*

Please select an option

Please give details*
Please give details

Please give details of your symptoms

Are you able to carry out your normal activities?*

Please select an option

Have you suddenly lost any weight without trying?*

Please select an option

Please give details of your weight loss*
Please give details

Are the symptoms worsening?*

Please select an option

For back pain referral, do you currently have leg pain?

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Have you had any difficulties passing or controlling urine?*

Please select an option

Are you off work with this problem?*

Please select an option


We will inform your GP of your self-referral. Please tick 'No' if you do NOT wish your GP to be informed.*

Please select an option


Have you received, or are you currently receiving, treatment for this problem?*

Please select an option

Please give details*
Please give details

Are you currently taking any medication? *

Please select an option

Please give details*
Please give details


Do you suffer with depression or anxiety? *

Please select an option

Are your family and friends concerned about you?*

Please select an option

Please give details*
Please give details

Do you have any difficulties with thinking or understanding?*

Please select an option

Do you have any difficulties with hearing? *

Please select an option

If so, do you require access to a hearing loop?*

Please select an option

Do you feel this is related to your current problem? *

Please select an option

Do you have any problems with reading or writing? *

Please select an option

Do you have any difficulties with learning? *

Please select an option


Will you require an interpreter?*

Please select an option

What language would you need an interpreter for?*
Please select an option

Please provide us with any other information that you feel is relevant in the box below
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Do you require a chaperone for your face to face appointment? *

Please select an option

If you require a face to face appointment where would you rather be seen and at what time?
In order for us to plan your care please tick all days and times that are more convenient for you to attend an appointment. The service is open from 8am-7pm Monday to Friday.

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Where would you prefer to be seen?*
Please select a clinic

For clinic location details please go to Where We Do It

Please let us know what you are hoping to gain from our service*
Please give details

Where did you hear about our service?*

Please select an option

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MSK HQ
This questionnaire is about your joint, back, neck, bone and muscle symptoms such as aches, pains and/or stiffness. Please focus on the particular health problem(s) for which you sought treatment from this service. Under each heading, please tick the ONE box to indicate which statement best describes you over the last 2 weeks.

Pain/stiffness during the day
How severe was your usual joint or muscle pain and/or stiffness overall during the day in the last 2 weeks?*

Please select an option

Pain/stiffness during the night
How severe was your usual joint or muscle pain and/or stiffness overall during the night in the last 2 weeks? *

Please select an option

Walking
How much have your symptoms interfered with your ability to walk in the last 2 weeks? *

Please select an option

Washing/Dressing
How much have your symptoms interfered with your ability to wash or dress yourself in the last 2 weeks? *

Please select an option

Physical activity levels
How much has it been a problem for you to do physical activities (e.g. going for a walk or jogging) to the level you want because of your joint or muscle symptoms in the last 2 weeks? *

Please select an option

Work/daily routine
How much have your joint or muscle symptoms interfered with your work or daily routine in the last 2 weeks (including work & jobs around the house)? *

Please select an option

Social activities and hobbies
How much have your joint or muscle symptoms interfered with your social activities and hobbies in the last 2 weeks?*

Please select an option

Needing help
How often have you needed help from others (including family, friends or carers) because of your joint or muscle symptoms in the last 2 weeks? *

Please select an option

Sleep
How often have you had trouble with either falling asleep or staying asleep because of your joint or muscle symptoms in the last 2 weeks? *

Please select an option

Fatigue or low energy
How much fatigue or low energy have you felt in the last 2 weeks?*

Please select an option

Emotional well-being
How much have you felt anxious or low in your mood because of your joint or muscle symptoms in the last 2 weeks? *

Please select an option

Understanding of your condition and any current treatment
Thinking about your joint or muscle symptoms, how well do you feel you understand your condition and any current treatment (including your diagnosis and medication)? *

Please select an option

Confidence in being able to manage your symptoms
How confident have you felt in being able to manage your joint or muscle symptoms by yourself in the last 2 weeks (e.g. medication, changing lifestyle)?*

Please select an option

Overall impact
How much have your joint or muscle symptoms bothered you overall in the last 2 weeks? *

Please select an option

Physical activity levels
In the past week, on how many days have you done a total of 30 minutes or more of physical activity, which was enough to raise your heart rate? This may include sport, exercise and brisk walking or cycling for recreation or to get to and from places, but should not include housework or physical activity that is part of your job.*

Please select an option

If you click the Submit button and nothing appears to happen please check that you have filled out all the mandatory fields.

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