Progress SRQ Progress Self Reporting QuestionnaireIf you have any questions regarding the questionnaire, please do not hesitate to contact our practice on 02 6583 6900. Name*DateCurrent Self-Reported Pain At its best out of 10:12345678910In 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 10:12345678910Any aggravating factors?Any easing factors?Self-Reported TolerancesPlease provide comment on your tolerances for the following SittingLess than 5 (mins)5 (mins)10 (mins)15 (mins)20 (mins)25 (mins)30 (mins)35 (mins)40 (mins)45 (mins)50 (mins)55 (mins)60 (mins)greater than 60 (mins)WalkingLess than 5 (mins)5 (mins)10 (mins)15 (mins)20 (mins)25 (mins)30 (mins)35 (mins)40 (mins)45 (mins)50 (mins)55 (mins)60 (mins)greater than 60 (mins)Static StandingLess than 5 (mins)5 (mins)10 (mins)15 (mins)20 (mins)25 (mins)30 (mins)35 (mins)40 (mins)45 (mins)50 (mins)55 (mins)60 (mins)greater than 60 (mins)Dynamic standingLess than 5 (mins)5 (mins)10 (mins)15 (mins)20 (mins)25 (mins)30 (mins)35 (mins)40 (mins)45 (mins)50 (mins)55 (mins)60 (mins)greater than 60 (mins)Liftingless than 5 (kg)5 (kg)10 (kg)15 (kg)20 (kg)25 (kg)greater than 25 (kg)Carryingless than 5 (kg)5 (kg)10 (kg)15 (kg)20 (kg)25 (kg)greater than 25 (kg)Pushingless than 5 (kg)5 (kg)10 (kg)15 (kg)20 (kg)25 (kg)greater than 25 (kg)Pullingless than 5 (kg)5 (kg)10 (kg)15 (kg)20 (kg)25 (kg)greater than 25 (kg)Self-reported restrictions Please provide comment on any current physical restrictions due to your compensable injuryPhysical restrictionsPlease provide comment on any current physical restrictions due to your compensable injuryActivities of Daily Living Please provide comment on your ADLs. (No restriction, slight restriction, significant restriction, total restriction, not applicable.) Bed MakingNo RestrictionSlight RestrictionSignificant RestrictionTotal RestrictionNot ApplicableChild CareNo RestrictionSlight RestrictionSignificant RestrictionTotal RestrictionNot ApplicableCleaningNo RestrictionSlight RestrictionSignificant RestrictionTotal RestrictionNot ApplicableSelf-careNo RestrictionSlight RestrictionSignificant RestrictionTotal RestrictionNot ApplicableShoppingNo RestrictionSlight RestrictionSignificant RestrictionTotal RestrictionNot ApplicableCookingNo RestrictionSlight RestrictionSignificant RestrictionTotal RestrictionNot ApplicableGardeningNo RestrictionSlight RestrictionSignificant RestrictionTotal RestrictionNot ApplicableTransfersNo RestrictionSlight RestrictionSignificant RestrictionTotal RestrictionNot ApplicableVaccumingNo RestrictionSlight RestrictionSignificant RestrictionTotal RestrictionNot ApplicableIroningNo RestrictionSlight RestrictionSignificant RestrictionTotal RestrictionNot ApplicableWashingNo RestrictionSlight RestrictionSignificant RestrictionTotal RestrictionNot ApplicableWork status Are you currenty working?YesNoHow many hours per day?1234567891010+How many days per week?1234567GoalsMedication Please list any medications that you are currently taking/prescribed. Please list medication name, dosage and times taken per day.
