MAIDSTONE&TUNBRIDGE WELLS NHS TRUST    KENT COMMUNITY HEALTH NHS TRUST

INFORMATION FOR PATIENTS ABOUT THE PHYSIOTHERAPY SELF-REFERRAL SERVICE

WHAT IS SELF-REFERRAL?

A service has been set up to provide direct access to Outpatient Physiotherapy for adults with back, neck or joint problems, or following injury.

HOW DO I ACCESS THE SERVICE?

Please print and complete the self-referral form below. It is important to fill out the form as fully as possible. Take or send the form to the Outpatient Physiotherapy Department at one of the hospitals listed.

WHAT WILL HAPPEN NEXT?

Your form will be processed by a Physiotherapist. You will then be contacted based on the information you have supplied.

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 doing them normally 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 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.

PAINKILLERS

‘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 are advised to see your GP

HOT OR COLD

Some people find that a hot water bottle wrapped in a towel on the affected area for 10minutes can reduce pain, whilst others prefer using a pack of frozen peas wrapped in a damp towel for 10minutes.

N.B. Be aware that hot and cold can burn and that you need to check (every 5minutes) that your skin does not become very red or blotchy; if this happens stop use. 

OUTPATIENT  PHYSIOTHERAPY DEPARTMENTS WHICH WILL ACCEPT YOUR PHYSIOTHERAPY SELF-REFERRAL FORM

Maidstone General Hospital                                    Hawkhurst Community Hospital       

Hermitage Lane High Street

Maidstone  Hawkhurst

ME16 9QQ TN18 4PU

Tel: 01622 224300 Tel: 01580 753412

Fax: 01622 224561 Fax: 01580 752668

Churchill Centre                                                          Outpatients Physio

Preston Hall                                                                 Coxheath Clinic

Aylesford                                                                      Heath Road, Coxheath

ME20 7NJ                                                                    Maidstone ME17 4AH

Tel: 01622 225722                                                      Tel: 01622 741860

Fax: 01622 225725                                                     Fax: 01622 749179

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             NAME:                                                  DOB:

    ADDRESS:                                                  TELEPHONE NUMBERS

                                                                                       HOME:

                                                                                       WORK: 

                                                                                       MOBILE:

Symptom History

Please tick as appropriate:

When did this problem start?  Less than 2 weeks, 2-6 weeks, 4-6 weeks, 6-12 weeks, more than 12 weeks? 

Is the problem;

                         new?    □                             ongoing?  □    

            getting better?□                                  getting worse?  □                   staying the same?          □

Does it wake you at night?                                            Yes      □                               No       □

Is the problem stopping you from working?                   Yes      □                               No       □

Is there anything the problem is stopping you doing?      Yes      □                               No       □

Please Specifiy:

Pain 

If you have pain please indicate how severe your pain is on this line on a scale of 0—10.:

                       0       1          2           3             4          5          6          7         8          9         10

Medical History

Please tick as appropriate 

Have you consulted your GP about this problem?               Yes □                                       No           □

Have you tried anything to help with your problem?  (e.g. pain killers, exercise, other treatment)

                                                                              Yes            □                                       No           □

Please specify:

Have you had Physiotherapy  for the same problem in the last 6 months?     Yes            □              No            □

If so where did you have your physiotherapy?

Please take your completed referral form or send it to your nearest Out-patient Physiotherapy Department:

If you have any queries please contact :

Churchill Centre .Preston Hall  01622 225722

Coxheath Clinic   01622 741860

Hawkhurst Community Hospital  01580 753412

Maidstone Hospital 01622 224300