Request for NHS follow-up Physiotherapy after suggestion from GP / First Contact Physiotherapist - Ashbourne & Hilton Physiotherapy & Sports Injury Centre

In order for us to tie your request to your original GP / FCP appointment we require the following:

When did you speak to your GP / FCP about this problem

Name of who you spoke to?

Your Details:

Name *
First
Last

Date of Birth

Address *
Address Line 1
City
State / Province / Region
Postal Code

Preferred Telephone Number *

Alternative Telephone Number

Email *

Checkboxes
Please tick if you agree to us contacting you with service updates, information & newsletters & discount codes. We will not share with 3rd parties.

G P Practice *

Please give us a brief description of your problem, for example, what part of your body is troubling you and has there been an injury?

Is the problem:
Worsening?
Staying the same?
Gradually improving?

How severe is the pain?
Selected Value: 1

Use the sliding scale to score the severity of your pain. 0 = no pain, 10 = worst pain imaginable.

When did the problem start?

Are you getting pins and needles or numbness associated with this problem?
Yes
No

Is the pain disturbing your sleep?
No
Yes a little
Yes a lot
Not sleeping

Are you able to carry out you daily work / chores?
Yes
Yes but restricted
No

Medical Checklist.

We ask these questions for your safety. Please contact us or ask at your appointment if you have any queries or are uncertain.

Pre-existing medical conditions
Steroid Treatment
Epilepsy
Cancer
Heart/chest condition
Pacemaker
Anti-coagulant Therapy
Osteoporosis
Major Allergies
Diabetes
Autoimmune Disorders
Blood Disorders
Have you had any of the above? If Yes, please select.

Female Patient Only
Gynaecological Conditions?
HRT?
Are you Pregnant?

Are you currently seeing your Doctor for any other conditions? If yes please give details:

What medication are you currently taking?

Please tell us about any recent operations or past operations that might affect your current problem

I confirm the information given is accurate and consent to physiotherapy, noting that my therapist is likely to need to see and touch the injured part of my body. I will immediately inform the therapist if, at any stage, I have concerns or reservations about the treatment proposed. *
Signature of patient or person with parental responsibility / person legally entitled to sign on behalf of a person who lacks capacity

I confirm that I am aware that there is a GDPR Privacy Notice available to access on the website (www.ashbournephysio.co.uk) and consent to Ashbourne & Hilton Physio Centres holding & processing my personal data as outlined. I understand that I may withdraw my consent in writing at anytime but recognise the clinic has legal & contractual obligations to adhere to. I understand it is my responsibility to inform the clinic of an changes in my details. *
Signature of patient or person with parental responsibility / person legally entitled to sign on behalf of a person who lacks capacity

Date *

Please check that all your information is correct before submitting.