Perinatal Self-Referral Form for Physiotherapy Hereford
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Please refer to your local physiotherapy services via your GP’
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Full Name
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Address
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Postcode
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Your Contact Phone Numbers:
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Home Phone Number:
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Mobile Phone Number:
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Date of birth
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GP Practice
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Expected Due Date
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Number of weeks after delivery
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Number of previous pregnancies
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* Input digits (0 - 9)
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Number of previous deliveries
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* Input digits (0 - 9)
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Please give a brief description of your symptoms, or why you wish to see a physiotherapist
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Are you currently pregnant or within one year of giving birth?
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--- Select Option ---
Yes
No
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Do you sometimes experience accidental loss of urine on exercises, or are you unable to make it to the toilet on time?
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--- Select Option ---
Yes
No
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Do you experience pain or discomfort with sexual intercourse?
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--- Select Option ---
Yes
No
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Do you sometimes have a feeling of increased pelvic pressure or sensation of your pelvic organs slipping down or falling out?
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--- Select Option ---
Yes
No
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Do you sometimes experience loss of faeces or flatus or difficulties with your bowels?
--- Select Option ---
Yes
No
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How long have you had this problem? (Days, weeks, months, years)
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Have you had physiotherapy for this problem in the past? (If yes, please give details)
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Please list ALL the medications you are currently taking:
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