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Musculo-Skeletal Self Assessment*

©Restore Physiocentres


This questionnaire has been designed to assess your musculoskeletal condition. The report will give you an indication of how much at risk you are of developing Musculo-skeletal issues and the condition of your muscles and joints

Name
Age
Gender Male   Female   Other
Company
Occupation
Tel
Email

Part A : Are you at risk ?

  1. How often are you uncomfortably aware of any part of your body?

    Never   Sometimes   Often
    Specify area/areas
    Neck Shoulder Upper back Lower back
    Forearm Elbow Wrist Hip & Buttocks
    Knee Calf Ankle Foot
  2. On an average how many hours a day, do you spend seated at work?

    Sit less than 3 hrs
    Sit 3-6 hrs
    Sit more than 8 hrs
  3. How many times do you exercise in a week?

    Every day
    3-4 times a week
    Rarely/ Never
  4. Are able to work a whole day without fatigue?

    Yes, 8 hrs/ day
    2-6 hours /day
    Yes, less than 2 hrs / day
  5. Do you have stiffness in any joint?

    Never
    Sometimes
    Yes, after sitting for more than 30 minutes
    Specify area/areas
    Neck Shoulder Upper back Lower back
    Forearm Elbow Wrist Hip & Buttocks
    Knee Calf Ankle Foot
  6. Does any of your joints creak?

    Never
    Yes, but no discomfort or pain
    Yes, with discomfort and/or pain
    Specify area/areas
    Neck Shoulder Lower back
    Wrist Knee Ankle
  7. Do you experience a catch in any part of your body?

    Never Sometimes Often
    Specify area/areas
    Neck Shoulder Upper back Lower back
    Forearm Elbow Wrist Hip & Buttocks
    Knee Calf Ankle Foot
  8. Do you have trouble climbing up or down stairs?

    Never Sometimes Often

  9. Do you get swelling in any of your joints ?

    Never Sometimes Often
    Specify area/ areas
    Elbow Wrist Knee Ankle
  10. How often have you experienced pain episodes, on average, during the past three months?
    Never Sometimes Often
    Specify area/ areas
    Neck Shoulder Upper back Lower back
    Forearm Elbow Wrist Hip & Buttocks
    Knee Calf Ankle Foot



Part B: Test yourself


Attempt to perform the activity as described and answer the following questions as accurately as possible





* Disclaimer:
This Questionnaire is not intended as a diagnostic tool. It is not a substitute for diagnosis by a physician or a physical therapist.
This tool is developed by Physical Therapists and is currently undergoing testing for reliability and validity.

International Partner: American Physical Therapy Association

©2019 Restore Physiocentres