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Self-referral for Pelvic Health Physiotherapy (Bristol)

Who can the Pelvic Health Physiotherapy team help?
This service is available for women and people assigned female at birth, who are over the age of 16 and have any of the symptoms listed below.

Physiotherapy can help a range of pelvic health conditions which include:

Problems with your pelvic floor muscles at any stage in life:
•    Leaking urine
•    Leaking poo/wind
•    Bladder or bowel urgency
•    Pelvic organ prolapse
•    Pelvic pain

Problems occurring in pregnancy or after birth:
•    Pelvic girdle pain
•    Lower back pain 
•    Rib pain 
•    Hip pain 
•    Coccyx pain

These are common problems that can affect women and people assigned female at birth but they are not something you have to put up with, seeing a pelvic health physiotherapist can help to reduce or resolve these problems.

What is self-referral and what do I need to do?
Self-referral is another way of getting to see a pelvic health Physiotherapist. It means that you don’t need to see the GP and wait for them to refer you. 

Please complete all questions on the form, this is to help the Physio team decide on the correct treatment for you.  Any incomplete forms will not be accepted and you risk not being seen by the physio team.

If you are unable to complete the form, please ask your GP, Midwife or healthcare professional for help.

Who is the self-referral NOT for?
The referral is not for men, children or for separation of the stomach muscles (diastasis recti of the abdominus muscle).  These will need to be referred to the Pelvic Health team by your GP.

What will happen next?
A specialist Pelvic Health Physiotherapist will look at the information you have written on the form and then once you are near the top of the waiting list you will be contacted with an appointment.  The treatment you receive will be the same as if your GP had referred you.

How do I know if I should see my GP?
If you have any concerns, you can always make an appointment to see your GP in the usual way and ask for a Physiotherapy referral or self-refer once you have seen them.

All questions on this form marked with an asterix* require an answer.

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.

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.

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.

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.

    Your pelvic health problem

    Your symptoms - please select all that apply.

      Other (please specify)
      Other (please specify)
      If your symptoms are getting worse, please explain how?