Physio4Staff Referral Form

We will aim to contact you via telephone within 3-5 working days on receipt of your referral.

By completing this referral form, you accept responsibility for attending your planned appointments, failure to attend or multiple cancelled appointments will result in discharge from the service.

1Screening Questions

2Your Details

3Musculoskeletal Health Questionnaire (MSK-HQ)

Unique ID

Are you employed directly by Hull University Teaching Hospitals NHS Trust?(Required)

Yes

Unfortunately, we cannot accept your referral unless you are directly employed by Hull University Teaching Hospitals NHS Trust. Please seek advice from your GP.

Are you under the care of a rheumatology, orthopaedics or neurosurgery consultant?(Required)

Yes

Unfortunately, we cannot accept your referral if you are under the care of one of these consultants. Please seek advice from your consultant or your GP.

Are you experiencing problems that are non-musculoskeletal, such as vestibular or falls?(Required)

Yes

Unfortunately, we cannot accept your referral if you experiencing non-musculoskeletal problems, such as vestibular or falls. Please seek advice from your GP.

Are you pregnant?(Required)

Yes

Unfortunately, we cannot accept your referral if you are pregnant. Please seek advice from your GP, your midwife, or your consultant.

Your Name(Required)

Forename Surname

Your Date of Birth(Required)

Your Work Email Address(Required)

Enter Email Confirm Email

Your Mobile Phone Number(Required)

Do you consent to receiving SMS text messages from us?(Required)

Yes

Your Work Phone Number

Your Home Phone Number

Your Home Address(Required)

Street Address Town / City Postcode

Your GP's Address(Required)

Name of your GP Street Address Town / City Postcode

Do you use the NHS app?(Required)

Yes

Your Job Title(Required)

Are you currently off sick from work?(Required)

Yes

Where would you like to receive treatment?(Required)

Castle Hill Hospital

Hull Royal Infirmary

Please briefly describe the problem:(Required)

How long ago did this problem start?(Required)

0-6 weeks ago

6-12 weeks ago

3-6 months ago

6+ months ago

Are you currently under the care of a consultant for this problem?(Required)

Yes

Musculoskeletal Health Questionnaire (MSK-HQ)

This questionnaire is about your joint, back, neck, bone and muscle symptoms such as aches, pains and/or stiffness.

Please focus on the particular health problem(s) for which you sought treatment from this service.

For each question, select one response which describes you over the last 2 weeks.

1. Pain and stiffness during the day(Required)

How severe was your usual joint or muscle pain and/or stiffness overall during the day in the last 2 weeks?

Not at all

Slightly

Moderately

Fairly severe

Very severe

2. Pain and stiffness during the night(Required)

How severe was your usual joint or muscle pain and/or stiffness overall during the night in the last 2 weeks?

Not at all

Slightly

Moderately

Fairly severe

Very severe

3. Walking(Required)

How much have your symptoms interfered with your ability to walk in the last 2 weeks?

Not at all

Slightly

Moderately

Severely

Unable to walk

4. Washing and dressing(Required)

How much have your symptoms interfered with your ability to wash or dress yourself in the last 2 weeks?

Not at all

Slightly

Moderately

Severely

Unable to wash or dress myself

5. Physical activity levels(Required)

How much has it been a problem for you to do physical activities (e.g. going for a walk or jogging) to the level you want because of your joint or muscle symptoms in the last 2 weeks?

Not at all

Slightly

Moderately

Very much

Unable to do physical activities

6. Work and daily routine(Required)

How much have your joint or muscle symptoms interfered with your work or daily routine in the last 2 weeks (including work and jobs around the house)?

Not at all

Slightly

Moderately

Severely

Extremely

7. Social activities and hobbies(Required)

How much have your joint or muscle symptoms interfered with your social activities and hobbies in the last 2 weeks?

Not at all

Slightly

Moderately

Severely

Extremely

8. Needing help(Required)

How often have you needed help from others (including family, friends or carers) because of your joint or muscle symptoms in the last 2 weeks?

Not at all

Rarely

Sometimes

Frequently

All the time

9. Sleep(Required)

How often have you had trouble with either falling asleep or staying asleep because of your joint or muscle symptoms in the last 2 weeks?

Not at all

Rarely

Sometimes

Frequently

Every night

10. Fatigue or low energy(Required)

How much fatigue or low energy have you felt in the last 2 weeks?

Not at all

Slight

Moderate

Severe

Extreme

11. Emotional wellbeing(Required)

How much have you felt anxious or low in your mood because of your joint or muscle symptoms in the last 2 weeks?

Not at all

Slightly

Moderately

Severely

Extremely

12. Understanding of your condition and any current treatment(Required)

Thinking about your joint or muscle symptoms, how well do you feel you understand your condition and any current treatment (including your diagnosis and medication)?

Completely

Very well

Moderately

Slightly

Not at all

13. Confidence in being able to manage your symptoms(Required)

How confident have you felt in being able to manage your joint or muscle symptoms by yourself in the last 2 weeks (e.g. medication, changing lifestyle)?

Extremely

Very

Moderately

Slightly

Not at all

14. Overall impact(Required)

How much have your joint or muscle symptoms bothered you overall in the last 2 weeks?

Extremely

Very

Moderately

Slightly

Not at all

Hidden

MSQ-HQ Score(Required)

Physical activity levels(Required)

In the past week, on how many days have you done a total of 30 minutes or more of physical activity, which was enough to raise your heart rate? This may include sport, exercise and brisk walking or cycling for recreation or to get to and from places, but should not include housework or physical activity that is part of your job.

None

1 day

2 days

3 days

4 days

5 days

6 days

7 days

MSK-HQ © Copyright Oxford University Innovation Limited 2014. All Rights Reserved. The authors have asserted their moral rights. The authors acknowledge the kind support of Versus Arthritis in the development of the MSK-HQ.

Comments

This field is for validation purposes and should be left unchanged.