Postnatal Class Referral form

For those who are up to 12 weeks postnatal and either delivered at Chesterfield or are registered with a Derbyshire GP. 

If you delivered elsewhere and your GP is not a Derbyshire GP, you will need to ask a clinician (Midwife, GP, Health visitor) to refer you. 

Patient Details

Required
Required
Required

You can find your NHS number on the NHS App, or in any letters you have from the NHS, including appointment or medication letters.

You can also use the following link: https://www.nhs.uk/nhs-services/online-services/find-nhs-number/.

 

Date of Birth Required
Europe/London
Was your baby delivered at Chesterfield Royal Hospital? Required
Are you registered with a Derbyshire GP? Required

If you delivered elsewhere and your GP is not a Derbyshire GP you will need to ask a clinician (Midwife, GP, Health visitor) to refer you. 

Contact Details

Please make sure the contact details given are accurate as we will be relying on these to get in touch about arranging an appointment or to find out more information. 

*Please note these may be used by a physiotherapist to send information relating to your treatment and for service evaluation. Please let your therapist know if you do not consent to this.

Required

Postnatal Self Assessment

Required
Date of Birth of your Baby Required
Europe/London
Type of Delivery (Select all that apply) Required
Required
Since the birth of your baby, have you had any new pelvic floor symptoms affecting your bladder or bowel? Required
Required
Since the birth of your baby, have you had a dragging feeling or bulge of the vagina? Required
Required
Since the birth of your baby have you experienced pain in the pelvis, hips or lower spine? Required
Required
Required
Required
Required