SELF-REFERRAL FOR WALKING AID ASSESSMENT
(Instructions and Information are overleaf)
Waiting lists vary. You may wait several weeks. If your problem requires urgent attention – is severe or
getting worse please seek more urgent medical attention e.g. your GP or NHS 24 (08454 242424).
Surname
Date of Birth
First Name
Today’s Date
Title: Mr
Mrs
Miss
Ms
GP’s Name
Other:
GP surgery
Address
GP address
Postcode
GP Tel No
Tel: Home
CHI number
Work
(on your medical card, or from your
GP)
Mob
Reason for referral (please give a short summary of your problem)
How long have you had this problem?
Have you been to physiotherapy before?
Yes
No
When?
Have you been to a GP or other health professional?
When and Why?
Please let us know if you have any difficulty speaking english or other needs.
Information and instructions – for self referral for walking aid assessment.

If you would like a routine physiotherapy appointment for any equipment that might help your
walking please fill in this form

Send it in the post to Physio @ Home Team, St Roque’s, Astley Ainslie Hospital Edinburgh
EH9 2HL or email to Physio @ Home inbox

You will be contacted by our service to arrange an appointment

We will inform your GP you have attended this service