Self-referral to Women’s Health Physiotherapy | Barnsley Hospital NHS Foundation Trust

First name

Last name

Hospital Number

Date of Birth

Telephone

Address

Address 2

City/Town

Postal Code

Country

Do you need an Interpreter?

Yes

If Yes, what language?

Do you have any leakage of urine when you sneeze or cough?

Yes

Please circle, on a score of 0 - 10 (0/10 = not at all, 10/10 = a significant amount),

How much does your problem limit you with:

What date is your baby due?

How many pregnancies have you had in total?

How many children do you have and how old are they?

Do you have a twin pregnancy?

Yes

Why do you want to see a physiotherapist?

Please describe your current problem as it is now (for example pain, leakage of urine)

If you have pain, where do you feel it?

How long have you had the problem?

Have you had physiotherapy treatment before in this pregnancy or a previous pregnancy?

Yes

If Yes, for what problem and when?

If Yes, please state:

Are you on medication?

Yes

If Yes, please give details:

Occupation:

Are you off work due to your problem?

Yes

Hobbies and sports:

The following information should be read to rule out Cauda Equina Syndrome:

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
Changes when you try to urinate
Loss of sensation when you pass urine
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
Loss of sensation in genitals during sexual intercourse

Any combination or number of these warning signs could be symptoms of Cauda Equina Syndrome. Seek emergency medical help within 12 to 24 hours, _{Greenhalgh S., et al. (2017)}

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