Emergency Physiotherapy Referral

EMERGENCY PHYSIOTHERAPY

This service is for Carers living in GLOUCESTERSHIRE, who have developed pain or injury as a result of their caring role and whose condition is not so severe as to need urgent investigation. If your condition gets worse whilst waiting for Physiotherapy then SEE YOUR GP.

IF you are suffering with low back pain and if you have any changes regarding the following since your pain started;
Bladder or bowel function (i.e., Increasing difficulty when you try to urinate, increasing difficulty when you try to stop or control your flow of urine, loss of sensation when you pass urine, leaking urine or recent need to use pads, inabilityof knowing when your bladder is either full or empty, inability to stop bowel movement or leaking, loss of sensation when you pass a bowel motion)
Loss of sensation / tingling around genitals, back passage, buttocks or inner thighs
Erectile or ejaculation problems or loss of sensation in genitals during sexual intercourse
Loss of sensation/ tingling or numbness in both legs • Weakness in foot (i.e. floppy foot or inability to lift front of foot when walking)
If YES call NHS 111 or go to A+E IMMEDIATELY

IF you are suffering with constant pain and if you have any of the following;
History of Cancer; Unexplained weight loss; Feeling generally unwell/ fever/ lack of appetite
Relentless night pain that cannot be relieved by changing position in bed
Please contact with your GP as soon as possible to discuss if other investigations are required rather than self- referring to physiotherapy.

Completing the Form

If you wish to proceed with this self-referral please complete the form fully, giving as much information as possible.
Once you are at the front of the waiting list the physiotherapist will contact you to arrange an appointment for assessment.
Following this appointment a treatment plan will be agreed with you. If your referral is not appropriate for physiotherapy treatment then you will receive an email or phone call advising you to see your GP regarding this problem.
You will be informed when you have been discharged from treatment and will be provided with a summary of your progress.

First Name

Surname

Email address

Phone Number Please tell us a number that we could contact you on

Address Line 1

Address Line 2

Town

Postcode

Cared for person's additional needs Please highlight all that apply, hold down the control key and click to select.

Cared for person's other additional needs

Where is the pain? Please highlight all that apply, hold down the control key and click to select.

Pain score - 0 = No Pain, 1-3 = Mild Pain, 4-5 Moderate Pain, 6-7 Severe pain, 8-9 Very Severe Pain, 10 Worst Pain possible Please give one number as a score for your pain

Did any of these contribute to your pain/injury? Please highlight all that apply, hold down the control key and click to select.

Describe the problem Please describe how the injury occurred/when the pain started. Was it sudden or gradual? Describe any pain or limited movement

How long have you had the pain/injury for?

Is this pain getting Please click on the arrow and select your answer

Have you had this pain before? If Yes, when was this and what caused it? Please give a brief description

Is the pain or injury affecting your sleep?

Yes

What makes the pain better or worse?

Do you have any other medical conditions/ long tern disabilities? Have you had any recent surgery? If yes please briefly describe them

Is it affecting your ability to provide care? If you work have you been signed off sick? If yes please give a brief description of how you are affected

What do you hope will change as a result of having physiotherapy Please briefly describe this

FEEDBACK

The Parent and Carer Alliance C.I.C. is only able to get funding to provide services such as this one, through Grant funders, such as the Carers Gloucestershire Legacy fund and the Gloucestershire Community Foundation.
For funding to continue to be given, the Alliance needs to demonstrate how the support we provide helps families like yours. We need YOUR HELP and FEEDBACK to do this, as telling us what worked for you, helps funders understand why these services are needed

Agreeing to Give Feedback

Yes I agree to give feedback to help with future funding

CONSENT TO SHARE

I have read and understood the Parent and Carer Alliance Privacy Policy, click here to read the Privacy Policy
By proceeding, I consent to my personal data being collected and used as stated in the Privacy Policy, and in this Notice:
The Parent and Carer Alliance wish to collect and use this personal information for the following reasons:

To enable you to share information necessary for signing up for, and getting appropriate support from, services such as the Physiotherapy service, advocacy, training, information events, social activities and outings;
To provide you with support and guidance that is tailored to your needs;
To provide relevant future events/training and services by understanding your personal situation and experiences;
To help us to demonstrate need both locally and nationally to help the Parent and Carer Alliance work effectively with other organisations to improve the services provided;
To access funding sources to develop what we can offer to our members and to offer reduced price support;
To request feedback from you about what you think about any service or support provided to you by the Parent and Carer Alliance e.g. feedback to the Carers Gloucestershire Legacy fund and the Gloucestershire Community Foundation on the impact of advice and support that you have received as a direct result of their providing funding, which may involve them contacting you; and
To track information about the use of our website including information obtained via cookies to develop the website.

You can withdraw your consent to share your information at any time without detriment by email to info@parentandcareralliance.org.uk

CONSENT TO SHARE

YES I DO consent to share this to access support from the Physiotherapy service

Submit

Please click the submit button below to send this form. Once the button is clicked a please wait message should appear, then disappear and be replaced by a thank you message at the TOP of the form. You will then be emailed a copy of the form, showing that it has been submitted.

If this doesn't happen, please scroll up for any error messages, as questions with a red star need to be answered for the form to submit. Any issues click here to contact us