Dig…

Please indicate which of the following

areas of the body you have sought
treatment for from this service
(you may select more than one)

Headache, dizziness or poor balance

Neck

Shoulder/upper arm

Lower arm/wrist

Hand

Upper back/chest/abdomen

Lower back/pelvis

Hip/groin/thigh

Knee/lower leg

Ankle/foot

Other

How long have you had your current

joint, or muscle pain problem?
Less than 2-weeks

2 - 4 weeks

5 weeks - 3 months

4 - 6 months

7 - 12 months

13 months - 3 years

Over 3 years

Please select any underlying health

conditions that you may have from the
list below.
Cancer

Chronic pain

Circulatory Conditions

Diabetes

Digestive system conditions

Learning disability

Mental health condition e.g. depression,

anxiety

Arthritis

Neurological condition

Chronic kidney disease

Respiratory condition

Do you currently perform the

recommended amount of physical
activity in a typical week?
The recommended amount is at least two
strength-building activities and at least 150
minutes of moderate intensity activity
(increased breathing noted but you are able
to talk) or at least 75 minutes of vigorous
intensity per week (breathing fast and you
have difficulty talking).

Yes

No

During the last 3 months have you

been to see any health professionals
for your condition, either at your GP
practice, in other NHS services or
private care? Visits for specific
investigations or treatments (e.g.
xrays, surgery) are covered in the
next question.
Yes

No

Please tell us which health professional

you have seen, and the number of times
you have seen each healthcare
professional in the last 3 months for your
pain condition

Health professional Number of times you

have seen the health
professional

GP

Nurse

Consultant,
Disabled
specialist,
hospital doctor

Physiotherapist Disabled

Acupuncturist Disabled

Osteopath/Chiropractor
Disabled

Other

Have you had previous physiotherapy

treatment for this problem?
Yes

No

During the last 3 months have you

attended an NHS or private hospital
for any investigations or treatments
(e.g. xray, MRI scan, surgery, epidural
injection) related to your condition?
Please do not include any initial
appointments reported in the above
question.

Yes

No

SUBMIT

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