Self-referral form

Please do not attend your physiotherapy appointment if you have any of the following:

Positive COVID-19 test in the last 7 days?
Waiting for a COVID-19 test or the results?
New, continuous cough*
- * A new, continuous cough means coughing for longer than an hour, or three or more coughing episodes in 24 hours. If the patient usually has a cough, it may be worse than usual.
High temperature or fever
Loss of, or change in, sense of smell or taste
You live with someone who has either tested positive for COVID-19 or had symptoms of COVID-19 in the last 14 days?

Name

Date of birth

Contact number

email address

Referral category

Contract type

Where is your pain?

How long have you had this pain? (Weeks/months)

Are you off work because of this problem?

Please give a brief description of how the problem started

If you previously received treatment for this problem, please provide details

Click next to complete the COVID-19 Screening Questionnaire

Have you had an organ transplant?

Are you undergoing any treatment for cancer?

Are you having investigations for suspected cancer?

Have you had bone marrow or stem cell transplant in the last 6 months?

Are you taking immunosuppressant medication?

Have you been diagnosed with a severe lung condition?

Do you have any condition that increases your risk of getting an infection?

Are you taking any medication that makes you more likely to get an infection? (e.g. high dose steroids)

Do you have a serious heart condition?

Are you pregnant?

Are you over 70 years of age?

Do you have any non-severe lung conditions? (e.g. asthma)

Do you have heart disease?

Are you diabetic?

Do you have any kidney disease?

Do you have any Liver disease?

Do you have any condition that affects the brain or nerves? (e.g. Parkinson’s, MND, MS or CP)

Are you or anyone in your household ‘shielding’ due to immunosuppression or other health risk?

Have you had the Covid-19 Vaccine?

If so, have you had a second dose?

I confirm the information provided is truthful to the best of my knowledge. Yes

Signature

Date