Pelvic health physiotherapy self-referral form

Physiotherapy

The Trust's pelvic health physiotherapy service provides physiotherapy for women and birthing people whose pregnancy is booked at Queen Charlottes & Chelsea Hospital or St. Mary's Hospital.

The form below allows self-referral into this service.

If you are booked at another hospital, please speak with your midwife or GP for a referral to your local service.

If you are looking to book into our healthy pregnancy class which is a one-time class for women who are between 12-20 weeks pregnant, which provides expert advice on having a healthy pregnancy, please email imperial.pelvic.physiotherapy@nhs.net or call on 020 3313 3072 to book into the class.

If your pregnancy is booked at Imperial, and you would like to self-refer to physiotherapy, please accurately fill in the form below.

Should you have difficulty completing the form, you can instead be referred to the Trust's pelvic health physiotherapy by your midwife, obstetrician or via the maternity helpline (020 3312 6135).

Do not refer to physiotherapy without a review from a doctor first, if you have any of the following symptoms:

Unusual or unexpected vaginal bleeding
Blood on passing urine
Stinging or burning sensation when you pass urine
Blood in your stool
Unexplained persistent abdominal pain
Unexplained persistent abdominal bloating that does not come and go
Unexplained weight loss
Numbness or pins and needles in your lower limbs
Numbness around your buttocks or perineum
Inability to empty your bladder
Sudden changes in bowel habits without known cause

Please note: Your initial appointment may be in a group setting or one-to-one

Tick box of confirmation * Yes I confirm I do not have any of the above symptoms If I do have any of the above symptoms I have No

You cannot proceed along the referral.

About you

Are you currently pregnant? * Yes No

This physiotherapy service is for women or birthing people who are currently pregnant. If you are not pregnant please speak to your GP who can refer you to an appropriate physiotherapy service.

Is your pregnancy booked at Queen Charlottes & Chelsea Hospital or St Mary's Hospital? * Yes No

Unfortunately, we are only able to accept women or birthing people whose pregnancies are booked at Imperial Hospitals. Please discuss with your midwife or obstetrician at the hospital you are booked with or your GP so that you can be referred to an appropriate service.

First name * Surname * Hospital number * Date of birth * Postcode * Contact number * Email address * Which hospital are you delivering at? Queen Charlottes Chelsea Hospital St Marys Hospital Other

If you have selected other, please state which hospital

Estimated delivery date * Number of weeks pregnant * Condition you would like physiotherapy to help with * Lower back pain without leg pain Lower back pain with leg pain Pelvic pain front or back Hip or buttock pain Rib pain middle back pain Wrist pain and associated pins and needles andor numbness in hand - carpal tunnel syndrome Pelvic floor problems during pregnancy eg leaking urine leaking from the back passage constipation h If you select pelvic floor problems please provide details

NB: We only treat conditions that are related to pregnancy and stated in the following list. If your condition is not listed, it is unlikely that we can help your condition. Please contact your GP who will be able to refer you into a more appropriate service.

How long have you had these symptoms for? * Less than 6 weeks 6-12 weeks More than 12 weeks Do you require an interpreter, visual or auditory support? * Yes No

Please provide which language/ support needed

Are you a member of staff at the trust? * Yes No Please let us know your preferred method of consultation* Face to face Video appointment No preference

Last updated 9 Aug 2023

Pelvic health physiotherapy self-referral form

About you

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