Are you currently or have you previously received treatment for this condition?

Your details

Sex
You can find out your NHS number on the NHS website using the link at the top of this page.
I.e. hearing loss / speech difficulties
If so, please inform us of required language
What is your preferred method of contact?
Would you like to receive appointment reminder texts?
Are you happy for us to leave a voicemail?
Are you currently under, or have you recently been seen by, the Lancashire Care Foundation Trust Rheumatology Service?
If yes, did Rheumatology ask you to refer in?
Are you currently under, or have you recently been seen by, the Lancashire Care Foundation Trust Community Pain Service?

Reason for referral

Body part affected
How long have your symptoms been present?
My symptoms are:
Pain level today
0 being pain free and 10 being highest possible pain
If you are working, can you complete your normal duties?
Have you had any scans or investigations for this condition?
Which of the following scans or investigations have you had for this condition?
Do you have any other medical history we should be aware of?

Unfortunately we cannot accept self-referrals from people with a history of cancer. If you would like to access this service, please speak to your GP.

The Keele STarT Back Screening Tool

My back pain has spread down my leg(s) at some time in the last 2 weeks
I have had pain in the shoulder or neck at some time in the last 2 weeks
I have only walked short distances because of my back pain
In the last 2 weeks, I have dressed more slowly than usual because of back pain
It's not really safe for a person with a condition like mine to be physically active
Worrying thoughts have been going through my mind a lot of the time
I feel that my back pain is terrible and it's never going to get any better
In general I have not enjoyed all the things I used to enjoy
Overall, how bothersome has your back pain been in the last 2 weeks?

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