Assessment Type * Date of Assessment
First Name * Last Name * Date of Birth
Employee Number * Address Line 1 Gender Address Line 2 Phone Number Address Line 3 Email * City/Town Postcode Occupation Neck Shoulders Upper Back Lower Back Hips Knees Calves Other - please outline in text box Elbows Wrists Hands Yes No Feet Ankles Multiple Allergies Hearing or Sight Impairment Cardiovascular Conditions (such as Heart Disease, Pacemaker, Blood Disease, Angina, Anaemia) Cancer Respiratory Conditions (such as Asthma, COPD, Sleep Apnoea) Genitourinary (conditions affecting Urinary Bladder, Kidneys, Reproductive Organs) Dermatological Conditions (such as Psiorasis, Eczema, Dermatitis, Acne) Infections Muscle and Bone Conditions (such as Osteoporosis, Fibromyalgia) Yes No Arthritis (such as Rheumatoid, Osteoarthritis, Psoriatic, Reactive) Neurological Conditions (such as Stroke, Epilepsy, MS, Parkinson's) Psychological Conditions (such as PTSD, Anxiety, Depression) Endocrine Conditions (such as Hyper/hypothyroidism, Hashimoto's, Graves' Disease) Gastrointestinal (conditions affecting Stomach, Liver, Pancreas, Gall Bladder, Intestinal Tract) Have you had any surgical operations in the last 10 years? (please provide details) Height (cm) Weight (kg) Alcohol - Units per Week * Diabetes Are you taking any medications? If Yes, please list ALL the medications you are taking, the strength and dosage. Headaches/migraines Fatigue Generally, how do you feel upon waking up? * Generally, do you find it easy to sleep? * Do you wake in the night? * How often do you get relaxation or 'me time'? * Do you smoke tobacco products or alternative products e.g. electronic cigarettes? * If yes, how many per day If you have ever smoked, please indicate when you gave up
On average, how many days per week do you do a total of 30 minutes or more of physical activity? * If undertaking strenuous activity, how often do you manage 75 minutes or more per week? * Are you pregnant or is it possible you may be pregnant? Muscular or joint pain Swelling Pins and Needles Yes No Numbness How often do you experience symptoms? * Shortness of breath How long has your main symptom been present? * Less than 3 months 3 to 12 months 12 months to 2 years 2 to 5 years More than 5 years Which statement best describes your main symptom? * Always present (always the same intensity) Always present (level of symptoms vary) Often present (symptom free periods last less than 6 hours) Occasionally present (symptom occurs once to several times per day, lasting up to an hour) Rarely present (symptom occurs every few days or weeks) How did your main symptoms begin? * Injury at home Injury at work/school Injury in another setting Road traffic collision Cancer Medical condition other than cancer After surgery No obvious cause Other (please specify below) Seen GP Seen Orthopaedic Surgeon Seen Consultant Seen by musculoskeletal physician Seen by sports exercise practitioner Seen Physiotherapist / Osteopathy / Chiropractic Seen A&E If yes, please enter any dates and results of your investigations Have you had any investigations for your symptoms e.g. x-rays, scans, blood tests? How severe was your usual joint or muscle pain and/or stiffness during the day? * How severe was your usual joint or muscle pain and/or stiffness during the night? * How much have your symptoms interfered with your ability to walk in the last 2 weeks? * How much have your symptoms interfered with your ability to wash/dress yourself in the last 2 weeks? * In the last 2 weeks how much of a problem has it been for you to do physical activities? * How much have your symptoms interfered with with your work or daily routine? * How much have your joint or muscle symptoms interfered with your social activities and hobbies? * How much fatigue or low energy have you felt in the last 2 weeks? * How much have you felt anxious or low in your mood because of your joint or muscle symptoms? * How often have you had trouble with either falling or staying asleep because of your symptoms? * How often have you needed help from others because of your symptoms? * How confident have you felt in being able to manage your symptoms? * How much have your joint or muscle symptoms bothered you overall in the last 2 weeks? * Thinking about your current symptoms, how well do you feel you understand your condition? * Completely Very well Moderately Slightly Not at all Completely How many cups of tea do you consume daily? * How many cups of coffee do you consume daily? * How many glasses of water do you consume daily? * How many fizzy/energy drinks do you consume daily? * Do you find you get an energy 'dip' during the day * Do you ever miss breakfast? * Do you ever miss lunch? * Do you ever miss dinner? * How many portions of fruit do you have daily? * How many portions of vegetables do you have daily? * Do you get cravings for different foods? * Do you suffer from any digestive complaints? * I find I cannot take sufficient breaks or have to work additional hours to cope * I understand what I need to do to get my job done and where to go if I need help * Strongly Agree Slightly Agree Neutral Slightly Disagree Strongly Disagree Strongly Disagree Change within my organisation is communicated efficiently * I have to work intensively and find it difficult to achieve the deadlines set for me * I find I cannot complete all my tasks to the quality that I would like due to the pressure of work * I do not know how to prioritise my work * There are one or two individuals that cause problems/conflict at work and this is a concern to me * I have some control over my work and accept any limitations that exist within my role * I understand my role within the organisation and what is expected of me * Strongly Agree Slightly Agree Neutral Slightly Disagree Strongly Disagree Strongly Disagree We all work together as a team in my department and generally have a good relationship * I can rely on my manager to support me with any problem relating to my job * My manager provides constructive feedback and praise in relation to the job I do * I lead a purposeful and meaningful life * Strongly Agree Slightly Agree Neutral Slightly Disagree Strongly Disagree Strongly Disagree My social relationships are supportive and rewarding * I am engaged and interested in my daily activities * Strongly Agree Slightly Agree Neutral Slightly Disagree Strongly Disagree Strongly Disagree I actively contribute to the happiness and wellbeing of others * I am competent and capable in activities that are important to me * Strongly Agree Slightly Agree Neutral Slightly Disagree Strongly Disagree Strongly Disagree I am a good person and lead a good life * Strongly Agree Slightly Agree Neutral Slightly Disagree Strongly Disagree Strongly Disagree I rarely feel under stress and I am able to manage stress well * Strongly Agree Slightly Agree Neutral Slightly Disagree Strongly Disagree Strongly Disagree Voice other difficulties or concerns Please add any additional information you feel is relevant to your symptoms On a scale of 0-10 how important is it to you to make changes and improve your health?