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MSK Physiotherapy Self-Referral Form Boston House

    Adult MSK Physiotherapy Self-Referral Form Boston House

    Your Full Name*

    Address*

    Date of birth*

    Day*

    Month*

    Year*

    NHS Number (if known)

    Gender*

    Tel No.*

    Mobile*

    Email*

    GP Name and Address*

    Where on your body is your problem?*

    How long have you had this problem for?*

    What are your main symptoms?*

    Have you been to Wigan or Leigh A&E/Urgent Treatment Centre in the last 6 weeks for this problem? 

    Please add any other details that you think we need to be aware of:

    Are you a registered carer for someone?*

    Are you off work because of your problem?*

    Do you consider yourself to have a disability?*

    If yes, please give details:

    Do you consider require an interpreter?*

    If yes, please give details:

    Have you previously been, or are you currently under the care of the Pain Management Service?*

    Are you a member of staff at WWL?*

    Are you a member of the Armed Forces Community?*