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Home
Services
Adult Services
Adult Learning Disability Services
About Our Services
Carers Support
Children’s Services
Mental Health Services
Older People’s Services
Physical Disability Services
Emergency Department and Urgent Care Services
Attending the Emergency Department
Phone First
Emergency Department and Urgent Care Locations
GP and GP Out Of Hours
Community Pharmacy
Emergency Department Waiting Times
Altnagelvin Hospital Emergency Department
South West Acute Hospital Emergency Department
Urgent Care and Treatment Centre, Omagh Hospital
Hospitals
Altnagelvin Area Hospital
South West Acute Hospital
Facilities at South West Acute Hospital
Outpatients Clinics at South West Acute Hospital
Women’s Health Clinics at South West Acute Hospital
Erne Hospital
Omagh Hospital and Primary Care Complex
Outpatients Clinics, Omagh Hospital
Women’s Health and GUM Clinics, Omagh Hospital
Tyrone County Hospital
North West Cancer Centre
Grangewood
Lakeview Hospital
Roe Valley Hospital
Tyrone and Fermanagh Hospital
Car Parking
Waterside Hospital
Concessionary Car Parking
Community
Family Centres
Day Centres
Health Centres
Residential Homes
Supported Living
Healthy Living
Alcohol and Drugs
Be Active
Breastfeeding
Cancer Awareness
Concerned about suicide?
Eat Well
Children’s and Young People’s Mental Wellbeing
Later Years
Looking After Your Mental Health
Looking After Your Sexual Health
Managing the Challenge Programme
Neighbourhood Renewal
Stop Smoking
Traveller Health
Staff Health and Wellbeing
Health Improvement Leaflet Catalogue
About the Trust
Access to Information
Cookies Policy
Freedom of Information
Information Disclosure Log
Personal Information
Corporate Information
Our structure
Corporate Management Team and Trust Board
How we make decisions
Our priorities and performance
Financial Information
National Fraud Initiative
Emergency General Surgery – South West Acute Hospital
Fact Checker – Emergency General Surgery, South West Acute Hospital
Medical and Dental Education
Mental Capacity Act
No More Silos
Pathfinder
Pathfinder – Contact Us
Pathfinder Community Engagement
Pathfinder Health Summit
Research and Development
Transforming Your Care
Trust Board
2018 Trust Board Meeting Agenda, Minutes and Supporting Papers
2019 Trust Board Meeting Agenda, Minutes and Supporting Papers
2020 Trust Board Meetings: Agenda, Minutes and Supporting Papers
2021 Trust Board Meetings: Agenda, Minutes and Supporting Papers
2022 Trust Board Meetings: Agenda, Minutes and Supporting Papers
2023 Trust Board Meetings: Agenda, Minutes and Supporting Papers
Western Trust News
Involving You
Consultations
Equality and Diversity
Involving You – Contact Us
Latest Involvement News
10,000 Voices
Publications
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VC2020
VC2020
What is a Video Consultation?
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Home
Service
Physiotherapy
Self-referral to MSK Outpatient Physiotherapy
Self-referral to MSK Outpatient Physiotherapy
Self-referral to MSK Outpatient Physiotherapy (7)
Self-referral is available for adults over 16 who need support and advice to manage symptoms related to muscle strains/joint sprains/back and neck pain. This referral option is not available if you are under the care of a consultant for this problem, or if you have neurological, respiratory and/or continence conditions. If you have pregnancy related pain, please ask your GP/Midwife to refer you to the Pelvic Health/ Women’s Health Physiotherapy Service who do not currently accept self-referrals. Please note this is for patients who live within the Western Trust only.
Name
*
First
Last
Are you 16 Years of age or older ?
*
Please note that Direct Access Physiotherapy in the Western Trust is only available to prospective clients of 16 years and over.
Yes
No
Date of Birth
*
Please note that Direct Access Physiotherapy in the Western Trust is only available to prospective clients of 16 years and over.
Date Format: DD slash MM slash YYYY
Please note that Direct Access Physiotherapy in the Western Trust is only available to prospective clients of 16 years and over. If you are not yet 16 years of age you will not be able to refer yourself for this service
Address
*
Street Address
Town/City
County
Postcode
Your Health and Care Number / Hospital number (if known)
Email
*
Please enter your email address if you have access to an email account and wish to receive confirmation of your request.
Enter Email
Confirm Email
Phone
*
A telephone number is essential as this is the preferred method of communication with our service users. To ensure a timely response to your request for treatment, please ensure you have entered a telephone number where you can be contacted. If you do not have a home telephone number, please provide an alternative.
Can we leave a message at this number?
*
Yes
No
Do you require an interpreter?
*
Yes
No
If you require an interpreter, what language is required?
Do you require adjustments for reasons related to a disability?
*
Yes
No
Please outline your requirements.
Please indicate in which location your GP Practice is based
*
Derry/Londonderry
Limavady
Strabane/Castlederg
Dungiven
Omagh area
Fermanagh
Please select your GP Practice from the drop down below
*
Cityview Medical - Dr. McCallion & Partners
Glendermott Medical - Dr. O'Flaherty & Partners
Riverfront Medical - Dr. Healy and Partners
Bridge Street Family Practice - Dr. O'Kane & Partners
Foyleside Family Practice - Dr. Leeson & Partners
Abbey Medical Practice - Dr. Black and Partners
Oakleaf Medical Practice - Dr. Doherty & Partners
Park Medical - Dr. O'Donnell & Partners
Dr. Doherty
Quayside Medical Practice - Dr. Foy & Partners
The Aberfoyle Surgery - Dr. McCloskey & Partners
Bayview Medical Centre - Dr. McEvoy and Partners
Clarendon Medical - Dr. Lalsingh & Partners
Northside Medical Practice - Dr. Deane & Partner
Racecourse Medical
Eglinton Medical Practice - Dr. D R Patterson & Partners
The Health Centre - Dr. Tedders & Partners
Dr. Fullerton & Partner
Please select your GP Practice from the drop down below
*
Bovally Medical Centre - Dr. McQuillan and Partners
Limavady Health Centre - Dr. Henderson & Partners
Limavady Health Centre - Dr. Quinn & Partners
Rossair Family Practice - Dr. Pratt & Partners
Please select your GP Practice from the drop down below
*
Castlederg Group Surgery - Western Rural Healthcare
Dr. Fullerton & Partner
Family Practice, Strabane Health Centre
Mourneside Medical Centre
Riverside Practice - Dr. O'Flaherty & Partners
Please select your GP Practice from the drop down below
*
Dungiven Health Centre
Please select your GP Practice from the drop down below
*
Carrickmore Health Centre - Dr. Corry and Partners
Dromore Surgery - Dr. Reilly
Drumquin Healthcare - Dr. Scully
Drumragh Family Practice - Dr. Gallagher and Partners
Fintona Group Practice - Dr. Monaghan and Partners
Grange Family Practice - Dr. Pollock & Partners
Newtownstewart Medical Centre - Western Rural Healthcare
Sperrin Family Practice
Sperrin Family Practice - Dr. Hicks & Partner
Strule Medical - Dr. Deehan
Three Spires Surgery - Dr. O'Neill & Partners
Please select your GP Practice from the drop down below
*
Brookeborough Surgery - Brookeborough & Tempo Primary Care Services
Cuilcagh Medical Practice - Dr. Cunningham & Partner
Derrygonnelly Surgery - Dr. Khew
Devenish Practice - Dr. Guette
Dr. Cathcart & Partners
Dr. Maguire & Partners
Irvinestown Health Centre
Lakeland Health Village - Dr. Mallon & Partner
Lakeside Medical Practice
Rathmore Clinic
Tempo Medical Centre - Brookeborough & Tempo Primary Care Services
The Health Centre, Drumhaw, Lisnaskea
The Surgery - Western Rural Healthcare, Ederney
Please tick where you normally receive your care?
Foyle area
Omagh Hospital and Primary Care Complex
South West Acute Hospital
Did your GP/FCP suggest self-referral to Physiotherapy
*
Yes
No
Where is your main problem? Please only select ONE
*
Back
Neck
Shoulder
Arm
Elbow
Wrist
Hand
Chest
Hip
Knee
Leg
Foot
How long have you had this problem?
*
0-6 weeks
7-12 weeks
>13 weeks
>1 year
Have you seen your GP/FCP/other Healthcare Practitioner regarding this problem?
Yes
No
What did they say ?
Is this problem...
*
New
Return of old problem
Are the symptoms getting worse?
*
Yes
No
If yes, in what way?
Are you able to carry out your normal activities? (work, care for a dependant, sport)
*
Yes
No
If no, what are you having difficulty with?
What is your occupation?
Do you know what caused your problem?
*
Yes
No
If yes, please give details
Have you had any recent trauma or overuse that you may think is relevant to your symptoms?
Yes
No
If yes, please give details
Do you have any other medical condition or information that you think may be relevant e.g. Cancer, previous fractures, Diabetes, Osteoporosis?
*
Yes
No
If yes, please give details
Sometimes we miss what is most important to you, what is concerning you most?
*
Have you lost weight in the past 6 months for reasons you cannot explain?
*
Yes
No
If yes, how much weight did you lose?
Have you felt generally unwell over the last 6/12 months?
e.g. Temperature, Night sweats, Fatigue, New persistent cough, Change in bowel habit, Appetite, Unsteadiness, Falls
Yes
No
If yes, please give details
Have you developed Numbness / Tingling / Pins and Needles since the start of your problem?
*
Yes
No
If yes, where?
Since the onset of your problem do you have any of the following symptoms?
*
(We appreciate some of these questions are personal but they are required to rule out some serious conditions)
A new episode or a sudden change to your ability to control or to pass urine
A new loss of sensation to your inner thighs, genitals or back passage area
A new difficulty with Bowel function resulting in a loss of bowel control (soiling yourself)
A new difficulty in achieving or maintaining an erection or altered sexual function
None of the above
Calculation only - New Symptoms?
If you develop any new symptoms, after submitting this form, it is essential that you arrange for URGENT advice from your GP or attend your local Emergency Department.
Have you spoken to your GP about these new symptoms?
*
Yes
No
What did they say?
*
Calculation only - Symptoms Reported?
If you HAVE NOT seen a doctor for this symptom, it is essential that you arrange for URGENT advice from your GP or attend your local Emergency Department, DO NOT submit your form.
Name
This field is for validation purposes and should be left unchanged.
