If you would like to fill in the form by hand, click here to download a printable version.

Physiotherapy Self-Referral Form for Pregnant and Postnatal Women

Please only use this tool of you are currently pregnant, have been pregnant or given birth within the last year. Please use this tool if you want to have physiotherapy treatment because you are leaking from your bladder or back passage, you feel a bulge or heaviness down below, you experience pelvic - or back pain, you have had a C-section or you feel there is a gap between your tummy muscles. The questions in this form will help us to make sure we provide the best level of care for you. We will keep your answers confidential and they will not be linked to your medical records.
Full Name:(Required)
Address:(Required)
Marital Status:(Required)
Please include the frequency of these activities.
Date of Birth:(Required)
Your Contact Phone Numbers:(Required)
Home
Work
Mobile
Can We Leave a Message? (If so please check a box below)

Current Pregnancy

Baby Due Date:

Previous Pregnancies:

Mode(s) of Delivery:
Days/Weeks/Months/Years
Are your symptoms worsening?(Required)
How much does this problem affect your daily life?(Required)
How much does this problem affect your sleep?(Required)
Have you had to have time off work because of this problem?(Required)
Have you had any tests on your bladder/bowel/pelvis/back? (e.g. scans, urodynamics, sigmoid - or colonoscopy)(Required)

Since the onset of this problem, do any of the following apply to you?

Have you experienced unexpected bleeding or staining from the vagina?(Required)
Have you experienced persistent bloating that doesn’t come or go?(Required)
Have you experienced unexplained weight loss?(Required)
Have you experienced persistent abdominal pain?(Required)
Have you had regular cervical smears?(Required)
Have you had any abnormal smear results?(Required)
Do you have any numbness/tingling in the area between your legs (saddle area)?(Required)

Pregnancy related questions: Since being pregnant, have you experienced any of the following (if any of the below worry you, please contact your midwife immediately):

Increased headaches?(Required)
Visual disturbances?(Required)
Swelling (hands/legs/feet/face)(Required)
Itching hands or feet?(Required)
Is your baby moving normally?(Required)
If any of the below apply to you, please check the relevant boxes:(Required)