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Physiotherapy back groups form

Your information

If you would like to find out what happens to personal information held about you, please read the your personal information section on our privacy policy page for more information.

Please provide us with some additional information regarding your back pain. It is important you provide information which is as accurate as possible to ensure you are offered the correct management pathway to help your condition. Some questions are mandatory as indicated by a * next to the question.

Important information

If you have recently (within two weeks) or suddenly developed any of the following with the onset of your lower back pain and / or leg pain:

  • A change in your bladder function or bowel control. 
  • Altered sensation around your genitals or back passage.
  • Loss of sexual function (achievement of erection or ability to ejaculate, loss of vaginal sensation).

Do not complete this form and immediately call NHS 111. Reporting these recent symptoms and that they are linked to your back pain.

If you have any of the following:

  • Any unexplained weight loss (more than 5% of your bodyweight over the last 6 to 12months). 
  • Are feeling generally unwell / feverish. 
  • Have recently become unsteady on your feet. 

Do not complete this form and make an appointment with your G.P or call NHS 111, reporting these symptoms.
 
However, if you are subsequently told by your GP or NHS 111 that these symptoms do not need further investigation, then please complete this form

Your details

This field is hidden when viewing the form
OLD Name(Required)
Date of birth(Required)
Are you happy to be contacted via email, regarding your care, by Kent Community Health NHS Foundation Trust?(Required)

Please visit our communicating by email or SMS text page for details.

We ask this question so that we can better understand the health needs of our local population. If you would like to know more about why we ask this question, please read this leaflet on our website: Equality monitoring leaflet.
Do you require an interpreter?(Required)
Do you have a disability or impairment which requires you to need additional support at your appointment?(Required)
For example, you may require us to change the way we communicate with you.
How will you be travelling to your appointments with us?
This will help us to ensure you are booked into the most appropriate venues.

For anyone with back and / or leg pain, it is important we ask the following questions. These questions relate to a rare condition called Cauda Equina Syndrome which can affect the spinal cord and surrounding nerves. 

Please read and answer the questions below carefully. 

Recent onset (within two weeks) to a change in your bladder function (difficulty initiating or sensation of flow) or bowel control including loss of fullness sensation(Required)
Recent onset (within two weeks) of altered sensation around your genitals or back passage(Required)
Recent onset (within 2 weeks) of loss of sexual function (achievement of erection or ability to ejaculate, loss of vaginal sensation)(Required)

Information about your back pain

How long have you had your symptoms?
For example upper or lower back?
For example, sharp, achy, stiff.

Do you experience any pins and needles or numbness in your legs?
Do you get pain when you:
For example, x-ray or MRI results, history of back injury, previous back surgery.
Have you ever taken any of the following medication?
This field is hidden when viewing the form
OLD Have you ever taken any of the following medication?
Have you had any health problems/ conditions with the following?(Required)
0 being no pain, 10 being the worst pain imaginable.

0 being no pain, 10 being the worst pain imaginable.

Today, are there any activities that you are unable to do or having difficulty with because of your problem?(Required)
Please write down an activity and score using the following scale:
0 - unable to perform activity
10 - able to perform activity at the same levels as before

Activity
0-10 score
 
Thinking about the last two weeks tick if you agree to the following questions(Required)
Overall, how bothersome has your back pain been in the last 2 weeks?(Required)

Musculoskeletal health questionnaire

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.

Please select the statement that best describes you over the last two weeks.

Pain/stiffness during the day - How severe was your usual joint or muscle pain and/or stiffness overall during the day in the last two 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 two weeks?(Required)
Walking - How much have your symptoms interfered with your ability to walk in the last two weeks?(Required)
Washing/dressing - How much have your symptoms interfered with your ability to wash or dress yourself in the last two weeks?(Required)
Physical activity levels - How much has it been a problem for you to do physical activities (for example, going for a walk or jogging) to the level you want because of your joint or muscle symptoms in the last two weeks?(Required)
Work/daily routine - How much have your joint or muscle symptoms interfered with your work or daily routine in the last two 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 two weeks?(Required)
Needing help - How often have you needed help from others (including family, friends or carers) because of your joint or muscle symptoms in the last two 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 two weeks?(Required)
Fatigue or low energy - How much fatigue or low energy have you felt in the last two 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 two 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 two weeks (for example, medication, changing lifestyle)?(Required)
Overall impact - How much have your joint or muscle symptoms bothered you overall in the last two weeks?(Required)
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.

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.

Sessions

Once your details have been reviewed, your first appointment may be in our Early Back Intervention Group run by one of our senior Physiotherapists.

These group sessions are held regularly and are an introduction into physiotherapy. You can choose to either attend on-line or join one of our face to face sessions. 

We aim to provide you the quickest route to access Physiotherapy. Both virtual and face to face group sessions include the same information and advice. To reduce your wait time, we may invite you to attend a virtual group session held on Microsoft teams.

Please select your preferred session(s)(Required)
The group sessions are held regularly, please select your preferred sessions from the options below. All sessions provide exactly the same content whether face to face or virtual. If you select more than one option and you will be offered the soonest availability.

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