St. George’s Community Hydrotherapy Pool
AQUATIC PHYSIOTHERAPY SELF REFERRAL FORM
PERSONAL DETAILS:Today’s Date: ___/___/____
Name:______DOB: ______
Name you like to be called: ______
Address: ______Post code: ______
Home tel. no: ______Mobile no: ______
Email address:
Please tick the box if you agree to receive email updates regarding St George’s Hydrotherapy Pool. We will not share your email address with any other organisation or company.
ORGANISATION DETAIL:
Name of the organisation: ______
Address: ______Post Code: ______
Contact Tel: ______
Contact email:______
Are you? USER CARER
ABOUT YOU:
Where did you hear about St George’s Hydrotherapy Pool?
______
______
Why do you want to use hydrotherapy?(Pleasegive the name(s) of themedical problem(s) or conditions).
______
______
______
Will you be bringing a carer? Yes No
Your carer(s) name: ______
Do you need assistance with:
Sling Hoist? Getting to the pool?
Walking Frame? Entering in the pool? (Steps)
What do you hope to achieve from using hydrotherapy?
I.e. regain strength in muscles, aid recovery from fracture, weight loss
______
______
______
EMERGENCY CONTACT DETAILS:
Name: ______
Relationship to you: ______
Telephone contact number: ______
Address: ______Post Code: ______
MEDICAL INFORMATION:
Please fill in this form after you have read and understood the Terms and Conditions. Please make sure you answer every question and tick YES or NO as appropriate. Ask a member of staff if you are unable to read or understand any of the questions listed. Thank you!
Applicable to you?
(Please tick YES or No where appropriate) / YES / NO / IF ‘YES’ PLEASE ELABORATE
Do you suffer from low blood pressure
(Normal is 120/80 - 120 /90) / HR
Controlled? YES NO
Is your weight in excess of the evacuation hoist allowance ( 23 stone) / HR
Have you recently suffered a stroke, had a blood clot, heart attack, or a severe asthma attack / HR (if YES - please elaborate)
DATE:
Are you allergic to chlorine? / HR
Do you get angina attacks at rest? / HR
Are you or may you be pregnant? / HR
Do you suffer from shortness of breath at rest? / HR
Do you have shortness of breathwhen laying flat? / HR
Do you suffer from diabetes? / HR
Controlled? YES NO
Do you suffer from epilepsy? / HR
Controlled? YES NO
Do you have any open / infected wounds? / HR
Do you suffer from faecal incontinence? / HR
Have you had sickness or diarrhoea in the last week? / LR
Have you had radiotherapy treatment recently
(last 6 months)? / LR
Do you have any fear of water? / LR
Do you suffer from haemophilia? / LR
Do you have MRSA? / LR
Do you have any skin problems, or tubes such as a catheter? / LR (if YES - please elaborate)
Do you have any ear or eye problems that you feel we should be aware of? (please detail over leaf) / LR (if YES - please elaborate)
*IMPORTANT* If you have ticked ‘YES’ to any of the questions marked HR - you will need to get this form signed by your GP or nurse below before using hydrotherapy.
Please provide details of any other medical conditions:
______
______
______
______
______
GP/NURSE USE ONLY:
Please verify below that your patient is safe to use aquatic physiotherapy:
Signature______
PRINT NAME: ______
Practice/Surgery______
Date: ______
Contact Number: ______
DECLARATION:
‘I have read and understood the Terms and Conditions form’.
Signed:______
‘I have read, understood, and completed this form to the best of my knowledge.’
Signed:______
IMPORTANT: I give consent to share my medical information with the staff of St George’s Hydrotherapy Pool and to be contacted by them. Yes No
Data Protection:
The information contained in the referral meets the requirements of the Data Protection, PeterboroughCity Council Data Protection Policy and NHS
Peterborough Governance/Data Protection policy (Caldicott Guardian policy).
We have a legal responsibility to keep confidential all of the information held about you. The obligations that the Health & Social Care organisations have, together with the rights of every individual, are set out in the Data Protection Act 1998.
Please send the referral form to the address below.
St George’s Community Hydrotherapy Pool,
367 Dogsthorpe Road,
Peterborough,
PE1 3RE
01733 453 583
Equality Monitoring Form
Please tick appropriate answers:
1.Age: under 16□50 – 59□
16 – 21□60 – 69□
22 - 29□70 – 79□
30 – 39□80 +□
40 – 49□I would rather not say□
2.Do you consider yourself to have a disability?
Yes□No□Rather not say□
If yes, do have a: physical impairment □
sensory impairment□
learning disability□
mental health condition long term□
other health condition long term□
3.Gender
female□male□gender reassignment□
do you now, or have you ever considered yourself transgender□
I would rather not say□
4.Ethnicity
Asian or Asian BritishWhite
Bangladeshi□White British □
Indian□White Irish□
Pakistan□Any other white Background□
Any other Asian Background□please state ______
please state ______
Black or Black British Other Ethnic Group
African□Chinese □ Carribean □ Any other Ethnic Group □
Any other Black background□please state______
please state______I would rather not say □
Mixed
White and Asian□White and Caribbean□
White and Black African □Any other Mixed background□
please state ______
5.Religion or beliefs
Atheism□Agnosticism□Buddhism□
Christianity□Hinduism□Humanism□
Islam□Jainism□Sikhism□
any other Religion/Belief□please state______
No Religion or Belief□
I would rather not say□
6.Sexual orientation
Bisexual□Gay man□Heterosexual□Lesbian/ Gay Woman□
Other□I would rather not say□
7.Are you currently providing support to a partner, child, relative, friend or neighbour who could not manage without your help or/and support?
yes□no□I would rather not say□
1
St George’s Community Hydrotherapy Pool, 367 Dogsthorpe Road,
Peterborough, PE1 3RE
01733 453 583