Self-referral for Pelvic Health Physiotherapy

General screening questions

Please answer yes or no to the following questions.

These questions are about your general health, not just your pelvic health problem. It's important that you answer all of these questions and give more information in the box provided. This information will make sure you are cared for correctly and that any potential serious problems or 'red flags' are dealt with quickly. 

You will have an opportunity to tell us about your pelvic health symptoms further down the form.

Do you feel a burning or stinging sensation when you wee?*

YesNo

Do you have blood in your urine?*

YesNo

Have you had any unusual or unexpected bleeding or staining from the vagina?*

YesNo

Do you have blood in your poo? (without other symptoms of piles)*

YesNo

Do you have a persistent change in your bowel habit? (needing to go more often, having runny poo and sometimes tummy pain)*

YesNo

Do you have persistent lower tummy pain, bloating or discomfort? (always caused by eating and maybe associated with loss of appetite or significant weight loss)*

YesNo

If you have answered yes to one or more of the questions above, have you seen a GP?

YesNo

If you have seen a GP, please give details of this conversation in the box below.
If you haven't seen a GP but have answered yes to one or more of the general screening questions - please speak to a GP before referring yourself to physiotherapy and do not continue completing this form. 

Cauda equina syndrome (part A)

Cauda equina syndrome is a rare but severe condition where the nerves at the bottom of the spine become compressed. Symptoms of cauda equina are acute low back pain and/or leg pain accompanied by any of the other symptoms below.

Do you have acute (severe and sudden onset) low back pain?*

YesNo

Do you have pain going down both legs?*

YesNo

Cauda equina syndrome (part B)

Only complete this section if you answered yes to either of the questions above in part A about acute back pain or pain down both legs.

Do you have loss of feeling or pins and needles between your inner thighs or genitals?

YesNo

Do you have numbness in or around your anus or buttocks?

YesNo

Do you have altered feeling when using toilet paper to wipe yourself?

YesNo

Do you have increasing difficulty when you try to stop or control your flow of pee?

YesNo

Do you have loss of sensation when you pee?

YesNo

Do you leak pee or have a recent need to use pads?

YesNo

Do you have difficulty knowing whether your bladder is full or empty?

YesNo

Are you unable to hold on when you need to poo or do you leak poo?

YesNo

Do you have a loss of sensation in the vulva/vagina during sexual intercourse?

YesNo

If you have ticked that you have acute low back pain and/or pain going down both legs in part A and have answered yes to one or more of the other questions in part B

Now do one of the following actions depending on your symptoms:

• If your symptoms started less than 2 weeks ago or your symptoms are getting worse - please seek urgent medical attention at your nearest A&E department and do not continue filling in this form until you have been assessed by a doctor.
  
  
• If your symptoms started more than 2 weeks ago and your symptoms are not worsening, please book an urgent appointment with your GP. Do not continue completing this form until you have been assessed by a GP or doctor.
  
  

Referring yourself to Pelvic Health Physiotherapy

Please complete all your details and press submit.

Which hospital site would you like to attend?

Weston General HospitalBristol Royal Infirmary or St Michael's Hospital

Full Name*

Address line 1*

Address line 2

City/town*

Postcode*

Date of birth*

Email address*

Phone number*

Can we leave you a voice message?*

YesNo

Are you currently serving in the armed forces and require treatment that is unable to be provided within forces medical services?

YesNo

Does your condition prevent you from providing care to a dependent you live with?

YesNo

Have you ever been diagnosed with a learning disability?

YesNo

Do you need an interpreter?*

YesNo

If you ticked yes to needing an interpreter, which language?

What is your ethnicity?*

White - BritishWhite - IrishWhite - Any other White backgroundMixed - White and Black CaribbeanMixed - White and Black AfricanMixed - White and AsianMixed - Any other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - Any other Asian backgroundBlack or Black British - CaribbeanBlack or Black British - AfricanBlack or Black British - Any other Black backgroundOther Ethnic groups - ChineseOther Ethnic groups - Any other Ethnic groupPrefer not to say

Your pelvic health problem

Your symptoms - please select all that apply.

Pelvic floor dysfunction symptoms:

Stress urinary incontinence (leaking urine cough/sneeze/laugh/high impact etc)Bladder urgency/ frequency (the feeling of needing to empty the bladder urgently and/or frequently)Urgency urinary incontinence (not getting to the toilet in time)Faecal incontinence (leaking poo)Flatal incontinence (leaking wind)Faecal urgency (the feeling of needing a poo with little warning)Obstructive defecation (difficulty emptying the bowels)Pelvic organ prolapse (dragging sensation or a bulge, heaviness sensation in the vagina)Pelvic pain/ vulval pain/ dyspareunia/ bladder pain (pain with sexual intercourse, and/or chronic pain in the pelvic region)

Other (please specify)

If you have selected any of the pelvic floor dysfunction symptoms above please give a brief description of why you would like a physiotherapy assessment.

Pregnancy or postnatal musculoskeleteal related symptoms (under six months from delivery)

If you are over 6 months from delivery, ask your GP to refer you to MSK outpatient physiotherapy.

Lower back painRib painHip painCoccyx (tail bone) painPelvic Girdle pain

Other (please specify)

If you have selected one or more pregnancy or postnatal symptoms, please give a description of why you would like a physiotherapy assessment.

Duration - how long have you had this problem?*

DaysWeeksMonthsYears

Are your symptoms getting worse?*

YesNo

If your symptoms are getting worse, please explain how?

Are you, or have you been pregnant in the last year?*

Yes, I am pregnantI have been pregnant in the last yearNo

If you are currently pregnant, when is your due date?

If you have given birth, when was your baby born?