Initial SRQ

Initial – Self Reporting Questionnaire
Your Health Care Practitioner has asked that you complete an SRQ (Self Reporting Questionnaire). An SRQ enables the practitioner to assess your capabilities and also gives them vital information that is required in reports that need to be submitted to your insurance company for a review. There are 2 steps to this questionnaire, firstly please complete Section One and base your answers on your pre work place injury. For Section Two answers please bas your answers on your post work place pre injury. Once the form is completed, please return via email to info@enrichedhealthcare.com.au or fax 02 5524 7002. If you have any questions regarding the questionnaire, please do not hesitate to contact our practice on 02 6583 6900.
Name*
Email
Date
Section One: Pre Work Place Injury
Please complete the following based upon what you were able to do pre injury
At its best out of 10:
In the last week where 0= no pain and 10 = extreme pain how would you rate your pain? At its best out of 10:
At its worst out of 10:
Any aggravating factors?
Any easing factors?
Self-reported tolerances
Please provide comment on your tolerances for the following
Sitting
Walking
Static Standing
Dynamic standing
Lifting
Carrying
Pushing
Self-reported restrictions
Please provide comment on any current physical restrictions due to your compensable injury
Physical restrictions
Activities of Daily Living
Please provide comment on your ADLs. (No restriction, slight restriction, significant restriction, total restriction, not applicable.)
Bed Making
Child Care
Cleaning
Self-care
Shopping
Cooking
Gardening
Transfers
Vaccuming
Ironing
Washing
Work status
Are you currenty working?
How many hours per day?
How many days per week?
Goals
Medication
Please list any medications that you are currently taking/prescribed.
Please list medication name, dosage and times day.
Please list medication name, dosage and times day.
Section Two: Post Work Place Injury
Please complete the following based upon what are able to do now since the injury
At its best out of 10:
In the last week where 0= no pain and 10 = extreme pain how would you rate your pain? At its best out of 10:
At its worst out of 10:
Any aggravating factors?
Any easing factors?
Self-reported tolerances
Please provide comment on your tolerances for the following
Sitting
Walking
Static Standing
Dynamic standing
Lifting
Carrying
Pushing
Self-reported restrictions
Please provide comment on any current physical restrictions due to your compensable injury
Physical restrictions
Activities of Daily Living
Please provide comment on your ADLs. (No restriction, slight restriction, significant restriction, total restriction, not applicable.)
Bed Making
Child Care
Cleaning
Self-care
Shopping
Cooking
Gardening
Transfers
Vaccuming
Ironing
Washing
Work status
Are you currenty working?
How many hours per day?
How many days per week?
Goals
Medication
Please list any medications that you are currently taking/prescribed.
Medication:
Please list medication name, dosage and times day.

Initial Self-Reported Questionnaire

Initial SRQ

Initial – Self Reporting Questionnaire

Section One: Pre Work Place Injury

Self-reported tolerances

Self-reported restrictions

Section Two: Post Work Place Injury

Self-reported tolerances

Self-reported restrictions

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