Progress Self-Reported Questionnaire

Progress Self Reporting Questionnaire
If you have any questions regarding the questionnaire, please do not hesitate to contact our practice on 02 6583 6900.
Name*
Date
Current Self-Reported Pain
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
Pulling
Self-reported restrictions
Please provide comment on any current physical restrictions due to your compensable injury
Physical restrictions
Please provide comment on any current physical restrictions due to your compensable injury
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 taken per day.
Please list medication name, dosage and times taken per day.

Progress Self Reporting Questionnaire