Musculoskeletal Therapy Services (MSK) Self-Referral

Please select your area (Required)

Bexhill

Hastings and St Leonards

Rural Rother

I have read the information at the top of this page and do not have any symptoms that require me to contact NHS 111 or medical history that requires me to see my GP? (Required)

Yes - I confirm

Your details

Name (Required)

First

Last

Gender (Required)

Date of birth (Required)

Address (Required)

Email (Required)

Preferred contact Number (Required)

NHS number (if known)

If you don't know your NHS Number, you can find it at: Find your NHS number

Do you require an Interpreter (Required)

Yes
No

If Yes, what language (Required)

Is this problem (Required)

New
Flare up of an old problem
Ongoing long term problem

Have you had any of the following

Please give details of what your GP said (Required)

Are you pregnant? (Required)

Yes
No

If yes, please state how many weeks

Referral information

Is this problem stopping you from working? (Required)

Yes
No

Are your daily activities affected by this problem (Required)

Not at all
Midly
Moderately
Severely

Please describe your main current problem/symptoms

How long it has been going on for?

What has this stopped you from doing

Have you had physiotherapy for this problem/condition before? (Required)

Yes
No

If yes, please give details (Required)

Have you got any long term medical conditions and are you on medication (ie diabetes, cardiac problems)

Health information

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

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

Walking. How much have your symptoms interfered with your ability to walk in the last 2 weeks? (Required)

Washing/Dressing. How much have your symptoms interfered with your ability to wash or dress yourself in the last 2 weeks? (Required)

Physical activity levels. 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? (Required)

Work/daily routine. 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)? (Required)

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

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

Sleep. 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? (Required)

Fatigue or low energy. How much fatigue or low energy have you felt in the last 2 weeks? (Required)

Emotional well-being. How much have you felt anxious or low in your mood because of your joint or muscle symptoms in the last 2 weeks? (Required)

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

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

Overall impact. How much have your joint or muscle symptoms bothered you overall in the last 2 weeks? (Required)

Total MSK Score

Physical activity levels

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 house work or physical activity that is part of your job (Required)

Feedback

We would value your feedback regarding this form, eg. are there any questions you did not understand etc.

East Sussex Healthcare NHS Trust provides NHS hospital and community services throughout East Sussex

Contact NHS 111 urgently if you have recently developed:

Please see your GP initially if you have:

MSK Therapy Services Self-Referral

Your details

Referral information

Health information

Physical activity levels

Feedback