Centrica MyHealth - DSE Assessment Request Step 1 of 2 50% Please complete the details below and attach a copy of the DSE self-assessment and In-House DSE assessment.Following support from Functional Health you will receive a report with recommendations which will be uploaded to Workday.If you require any further support call MyHealth on 1336 option 4 and ask to be transferred to Functional Health specialist.Your detailsName First Last DateDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Employee detailsEmployee name First Last Date of birthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Payroll number Job role Hours worked per week Height (if known) Centimeters (cm) Feet and Inches Feet Inches Centimetres Weight (approx. if not known) Kilograms Stone Stone Lbs Kgs Does the employee wear glasses? No Yes Does the employee have any known disabilities? Yes No Brief reason for this referralDate of previous DSE assessmentDay12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is there any other information that may be relevant: e.g. history of any problems with work station, known medical conditionsPlease upload your employee’s DSE self-assessment here:Accepted file types: pdf, jpg, jpeg, doc, docx, Max. file size: 2 MB.Please upload your employee’s in-house self-assessment here:Accepted file types: pdf, jpg, jpeg, doc, docx, Max. file size: 2 MB.