Self-Referral to Carlisle Physiotherapy Service

1.	FILL IN ALL SECTIONS OF THIS FORM (check ‘Name’ is completed) and return page 1 only to Carleton Clinic Physiotherapy Department by:
Post (address overleaf), or 
Scan it and Email to: physioreferrals@cumbria.nhs.uk (do not attach photos)
2.	AFTER 10 DAYS, phone 01228 603122 between 10am and 2pm (WEEKDAYS ONLY) to 
book your appointment.

PATIENT DETAILS:	
Full Name:  	GP Name:  
	
Date of Birth:	 	Name of surgery:
SPENCER STREET SURGERY	
Today’s Date:  		
Your address:

	Your occupation:
	
Phone Numbers: 	Home -   	OK to leave message? Yes  No 	
			Mobile - 	OK to leave message? Yes  No 	
		  	Work -   	OK to leave message? Yes  No 	

REFERRAL DETAILS:	
Please give a brief description of your problem:
	
How much pain do you suffer?	0 = no pain	10 = most severe pain	
											
0	1	2	3	4	5	6	7	8	9	10	
Does your pain disturb your sleep? 	Yes  No 		
How long have you had this problem? 	
Are you off work because of this problem? Yes  No  If yes, for how long?	
Please give details of any other treatment or tests you have received for this problem:
	
If you have back and/or leg pain, do you have problems with bladder or bowel control?	Yes  No 	
Have you had any sudden weight loss (without dieting)? Yes  No 	
Have you had any other symptoms such as numbness, tingling or muscle weakness? Yes  No  
(If yes, please give details)	
Please list any current or past medical conditions and list your current medication(s): 
	
If you have a preference for a particular clinic location, please select:

 Eden Medical Group 
       Port Road	
 Carleton Clinic                                         Cumwhinton Rd	
 North Carlisle Medical Centre 
       Stanwix	
 Brampton Cottage Hospital 
       Brampton	

Note: You may be seen sooner if you can be flexible and go to any location.	

Not sure if physiotherapy is right for you?
Physiotherapy can be particularly beneficial if you are suffering from low back pain, neck pain, recent injuries such as strains and sprains or joint and muscular pain. You can also see a physiotherapist if you are a man or woman suffering with incontinence.

Unfortunately this service is not available if: 
•	you want to see a physiotherapist about a neurological or breathing problem
•	you need a home visit
•	you are under secondary school age (please note if you are under 16 you will need a parent or guardian to come to the assessment with you)
•	if you want physiotherapy following a recent operation you will need a referral from your surgeon
Please see your GP if you fall into one of these categories.

What will happen next?
** Allow 10 days for your referral to be processed, then phone 01228 603122 between 10am and 2pm Monday to Friday for your appointment.**

What can I do to help myself in the meantime?
Research has shown that resting for more than a day or so does not help and may actually prolong pain and disability. You may need to modify your activities initially, but the sooner you get back to normal activity the sooner you will feel better. Getting stiff joints and muscles working can be painful, but this is a normal response and not a sign of damage. Feeling a bit sore initially is also normal and often a good sign that you are making progress. Changing your position or activity frequently through the day will help to prevent and reduce stiffness. Try to build up your general activity gradually. 

Pain Relief?
Over the counter painkillers can be helpful. A pharmacist will be able to advise you on the appropriate tablets. If your symptoms continue to worsen you may wish to see your GP. If you have an old injury, you may find that holding a hot water bottle wrapped in a towel on the affected area for 10 minutes reduces pain, while for a new injury (hot and swollen joint) you can use a pack of frozen peas wrapped in a damp towel for 10 minutes. Please be aware that hot and cold can burn and that you need to check (every 5 minutes) that your skin does not become very red or blotchy. If this happens, stop.

Referring yourself to physiotherapy

Please complete this form to refer yourself to physiotherapy and return it to: 

Physiotherapy Department
Carleton Clinic
Cumwhinton Road
Carlisle
CA1 3SX