Chelsea and Westminster Hospital
NHS Foundation Trust

GP ACCESS PHYSIOTHERAPY REFERRAL FORM

PATIENT	REFERRER	
Name	«PATIENT_Forename1» «PATIENT_Surname»	Name	«PATIENT_Registered_GP»	
Address	«PATIENT_BlockAddress»	Address	«PRACTICE_BlockAddress»	
Telephone	«PATIENT_Main_Comm_No »	Telephone	«PRACTICE_Main_Comm_No»	
DoB	«PATIENT_Date_of_Birth»	Fax	     	
NHS Number	«PATIENT_Current_NHS_Number»	E-mail	     	
Gender	«PATIENT_Sex»	Date of Referral	«SYSTEM_Date»	
Interpreter Required	Yes 	No 	Signature	     	
Language	     	Investigations attached	     	
Ethnicity	     			
Please complete the following details fully to avoid delays in treatment	
Diagnosis:      

History of present condition:      

Date of onset

Is the patient off work because of this problem? 
If yes, for how long? 
Patients Occupation: 	Yes 	No 
     
     	
Is the pain affecting Work/ADL/ability as a main carer?	Yes 	No 	
Does the problem affect patient’s normal sleeping pattern?	Yes 	No 	
Is the patient experiencing neurological symptoms?
If yes, is the patient: 	Yes 	No 
	
Is the problem an acute flare up of a chronic condition?	Yes 	No 	
Has the patient recently undergone surgery for this or a related condition?	Yes 	No 	
Has the patient recently had a POP cast removed?	Yes 	No 	
Has the patient received physiotherapy for this condition in this last 3 months?	Yes 	No 	
Preferred Treatment location

Chelsea and Westminster Hospital	         Please fax the referral to 0208 746 8402

Peripheral Clinic					Please fax the referral to 0800 169 7068
	
Please note: Failure to complete this referral in full may result in the delay of the referral being processed or even possibly the referral being returned for completion