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Pelvic Health Physiotherapy Referral Form

About this self-referral form

What is self-referral and what do I need to do?

This form has been designed so you can access the most appropriate support. You may have been asked by a health professional to complete it, or you may have taken the decision to seek advice yourself. Self-referral allows you to access the pelvic health physiotherapy service without having to see your GP or a health care professional.

It takes approximately 8 minutes to complete.

Please complete all the questions fully as possible, as the more information we have about your symptoms the better we are able to support you.

What types of conditions can the Pelvic Health Physiotherapy Team help?

Below is a list of common problems that can often be helped with pelvic health physiotherapy:

Problems that occur during pregnancy or after birth such as:

  • Pregnancy related Pelvic Girdle Pain (PPGP)
  • Lower back pain
  • Separation of tummy muscles (Diastasis Recti)
  • Hip pain
  • Rib Pain

Problems at any stage in life:

  • Bladder and/or bowel problems such as leakage or difficulty controlling them
  • Pelvic organ prolapse
  • Pelvic pain

Who should NOT complete this form?

This form should not be used if you are under 16 years old. Please make an appointment to see your GP who can refer you if necessary.

What happens next?

Once you have submitted your self-referral from, a confirmation email will be sent to the email address you have provided. If you have not received a confirmation email, please check your Junk Mail folder.

A specialist pelvic health physiotherapist will look at the information you provided and place you on the correct waiting list.

If you are pregnant you should receive an appointment within 3 weeks of submitting this form, either by letter or phone call. You will be notified by way of letter, how long you can expect to wait for all other conditions.

Cauda Equina Syndrome

If you have you any of the following symptoms WITHIN THE LAST 2 WEEKS then please do not complete this form and call NHS 111 or attend A&E as you may require immediate medical attention:

  • loss of feeling pins and needles between your inner thighs or genitals
  • numbness in or around your back passage or buttocks
  • altered feeling when using toilet paper to wipe yourself
  • increasing difficulty when you try to urinate
  • increasing difficulty when you try to stop or control your flow of urine
  • loss of sensation when you pass urine
  • leaking urine or recent need to use pads
  • not knowing when your bladder is either full or empty
  • inability to stop a bowel movement or leaking
  • loss of sensation when you pass a bowel motion
  • change in ability to achieve an erection or ejaculate
  • loss of sensation in genitals during sexual intercourse

Please choose an option

Please do not complete this form and call NHS 111 or attend A&E as you may require immediate medical attention.

Symptoms in Pregnancy

If you are pregnant and have any of the following symptoms then please do not complete this form and instead call your midwife, GP or your local delivery suite Immediately as pelvic health physiotherapy is not appropriate at this time:

  • Persistent severe headaches
  • Any swelling of the face, hands or feet
  • Changes in your sight such as blurred vision or flashing lights
  • Reduction in your baby's movements
  • Itching on the palms of your hands, soles of your feet, shoulders or arms
  • Any recent vaginal bleeding or loss of fluids
  • Severe calf pain or severe pain in your chest

Please choose an option

Please do not complete this form and instead call your midwife, GP or your local delivery suite Immediately as pelvic health physiotherapy is not appropriate at this time

The Last Six Weeks

In the last 6 weeks if you have experienced any of the following symptoms and you have not spoken to your GP about them then please make an appointment to do so rather than continue with this self-referral form

  • Change in your normal bowel habit
  • Burning or stinging sensation when you pass urine
  • Unexpected bleeding or discharge from the vagina or back passage
  • Persistent abdominal bloating that does not come and go
  • Persistent abdominal pain
  • Loss of appetite and sensation of feeling full

Please choose an option

In the last 6 weeks if you have experienced any of the following symptoms and you have not spoken to your GP about them then please make an appointment to do so rather than continue with this self-referral form

Your GP

Please select a GP location

Please select an option

Personal Information

Please enter your first name

Please enter your surname

Please enter how you identify your gender

Please enter your preferred pronoun

Please enter your date of birth

Please select an option

Please enter information on your special requirements

Contact Information

Please enter a valid telephone number

Please enter your address. Must be at least 5 characters

Please choose an option

About Your Current Symptoms

Please choose an option

Please choose an option

Please enter how weeks pregnant you are

Please enter your expected delivery date

Please choose an option

Please enter your delivery date

Please enter at least 5 characters

Please select an option

Please enter at least 5 characters

0

Please enter a pain score

Please tell us how long have you had your current symptoms for

Please select an option

Please select an option

Please select an option

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Relevant Medical History

Please choose an option

Please enter more than 5 characters

Please choose an option

Please enter more than 5 characters

Featured Links

Medicines in Pregnancy

It's important to continue taking any medication prescribed unless your GP/specialist specifically tells you to stop. Please visit our Existing Health Conditions page for more information, or visit 'Bumps' ('Best Use of Medicines in Pregnancy').

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