Self-Referral Form – Nexus Health

NB: Please complete all the mandatory sections marked as asterisk *
Disclaimers

*I, (Person named on this form), confirm that the information provided below is accurate to the best of my knowledge

YES

*First Name and Surname:

*I confirm I have answered NO to all questions under the suitability check.

YES

Disclaimers
To help us provide your care, do you consent to AQP Physio Providers sharing your information with other organisations involved in your care? For example; your GP, other NHS Trust services, etc.

*I consent to my information being used/ shared to health care professionals for my treatment

YES

Exclusions/Eligibility

*Have you received physiotherapy through the NHS in the last 6 months for the same musculoskeletal problem (Delete or cross the options as appropriate)

YES-(Please contact your GP for advice on further referral) NO-(Please continue completing the self-referral form)

*I can confirm that I am 16 years old or over when completing this form.

YES

Date of referral ( /2025):
*Demographic Information

NHS Number
If your NHS number is unknown you can find this by: Contacting your GP practice, Accessing the NHS app Using the following link https://www.nhs.uk/nhs-services/online-services/find-nhs-number/ Providing consent to the provider to access the link to source your NHS number (Type YES to confirm consent)

Registered GP Practice

Email (if available)

How do you wish to be contacted (Delete as appropriate)

Do you need any help with accessing our service either for reading, understanding or mobility (Delete as appropriate)

Do you need an interpreter? (Delete as appropriate)

Do you require a Female or Male Practitioner for your physiotherapy consultations? (Choose as appropriate)

Do you require a chaperone? (Delete as appropriate)

Triage Questions

Have you had surgery in the last three months for the musculoskeletal problem you are referring for? (Delete as appropriate)

If Yes, please state What Surgery

If Yes, please state When and where did you have the Surgery

Are you off work or unable to continue caring for a dependant because of this problem (Delete as appropriate)

Clinical information

Has your GP or Consultant advised you to self-refer? (Delete as appropriate)

Which body part is affected? (Please write about the side, location(s)/ area(s) of pain)

How long have you had this problem for?

In the last two weeks how severe have your symptoms been on a scale of 0-10 (0-no pain, 10-severe pain)?

Are the symptoms getting worse?

Have you had any recent tests or investigation conducted related to your current symptoms? (If yes, please bring your report with you to your appointment if possible)

Are you currently taking any medication? (If yes, please bring your prescription list to your appointment if possible)

Please give a brief description of your problem, EG: pain, aches, location, has your GP/Consultant advised you to self-refer, any other details

Self-Referral suitability check

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