Physiotherapy Health Questionnaire (MSK) If you have been advised by the surgery to do so, please submit this form. About YouName First Last Date of Birth Day Month Year Contact NumberEmail Enter Email Confirm Email MSK-HQPlease focus on the particular health problem(s) for which you sought treatment from this service. For each question tick one box to indicate which statement best describes you over the last 2 weeks.Pain/stiffness during the day: How severe was your usual joint or muscle pain and/or stiffness overall during the day in the last 2 weeks?Please selectNot at all – 4Slightly – 3Moderately – 2Fairly severe – 1Very severe – 0Pain/stiffness during the night: How severe was your usual joint or muscle pain and/or stiffness overall during the night in the last 2 weeks?Please SelectNot at all – 4Slightly – 3Moderately – 2Fairly severe – 1Very severe – 0Walking: How much have your symptoms interfered with your ability to walk in the last 2 weeks?Please SelectNot at all – 4Slightly – 3Moderately – 2Severely – 1Unable to walk – 0Washing/Dressing: How much have your symptoms interfered with your ability to wash or dress yourself in the last 2 weeks?Please SelectNot at all – 4Slightly – 3Moderately – 2Severely – 1Unable to wash or dress myself – 0Physical activity levels: How much has it been a problem for you to do physical activities (e.g. going for a walk or jogging) to the level you want because of your joint or muscle symptoms in the last 2 weeks?Please SelectNot at all – 4Slightly – 3Moderately – 2Very much – 1Unable to do physical activities – 0Work/daily routine: How much have your joint or muscle symptoms interfered with your work or daily routine in the last 2 weeks (including work and jobs around the house)?Please SelectNot at all – 4Slightly – 3Moderately – 2Severely – 1Extremely – 0Social activities and hobbies: How much have your joint or muscle symptoms interfered with your social activities and hobbies in the last 2 weeks?Please SelectNot at all – 4Slightly – 3Moderately – 2Severely – 1Extremely – 0Needing help: How often have you needed help from others (including family, friends or carers) because of your joint or muscle symptoms in the last 2 weeks?Please SelectNot at all – 4Rarely – 3Sometimes – 2Frequently – 1All the time – 0Sleep: How often have you had trouble with either falling asleep or staying asleep because of your joint or muscle symptoms in the last 2 weeks?Please SelectNot at all – 4Rarely – 3Sometimes – 2Frequently – 1Every night – 0Fatigue or low energy: How much fatigue or low energy have you felt in the last 2 weeks?Please SelectNot at all – 4Slight – 3Moderate – 2Severe – 1Extreme – 0Emotional well-being: How much have you felt anxious or low in your mood because of your joint or muscle symptoms in the last 2 weeks?Please SelectNot at all – 4Slightly – 3Moderately – 2Severely – 1Extremely – 0Understanding of your condition and any current treatment: Thinking about your joint or muscle symptoms, how well do you feel you understand your condition and any current treatment (including your diagnosis and medication)?Please SelectCompletely – 4Very well – 3Moderately – 2Slightly – 1Not at all – 0Confidence in being able to manage your symptoms: How confident have you felt in being able to manage your joint or muscle symptoms by yourself in the last 2 weeks (e.g. medication, changing lifestyle)?Please SelectExtremely – 4Very – 3Moderately – 2Slightly – 1Not at all – 0Overall impact: How much have your joint or muscle symptoms bothered you overall in the last 2 weeks?Please SelectNot at all – 4Slightly – 3Moderately – 2Very much- 1Extremely – 0The MSK-HQ total score is the sum of items 1-14, using the response values provided © Copyright Oxford University Innovation Limited 2014. All Rights Reserved. The authors have asserted their moral rights. The authors acknowledge the kind support of Versus Arthritis in the development of the MSK-HQPhysical activity levels In the past week: on how many days have you done a total of 30 minutes or more of physical activity, which was enough to raise your heart rate? This may include sport, exercise and brisk walking or cycling for recreation or to get to and from places, but should not include housework or physical activity that is part of your job. None One Two Three Four Five Six Seven