During the last 12 months have you been prevented from carrying out normal activities (e.g.

job, housework, hobbies) because of this trouble:

No Right Left Bilateral

Neck ❏ ❏ ❏ ❏
Shoulders ❏ ❏ ❏ ❏
Elbows ❏ ❏ ❏ ❏
Wrists/Hands ❏ ❏ ❏ ❏
Upper back ❏ ❏ ❏ ❏
Lower Back ❏ ❏ ❏ ❏
Hips/Thighs/Buttocks ❏ ❏ ❏ ❏
Knees ❏ ❏ ❏ ❏
Ankles ❏ ❏ ❏ ❏

How often do you do stretching exercises at your workstation?

1. Never
2. Rarely
3. Sometimes
4. Often
5. Always

How frequently you practice any of the following?

Never Less than Monthly Weekly Daily

once a
month
Walking ❏ ❏ ❏ ❏ ❏
Running ❏ ❏ ❏ ❏ ❏
Group Sports (e.g. Football, ❏ ❏ ❏ ❏ ❏
basketball etc)
Swimming ❏ ❏ ❏ ❏ ❏
Stretching ❏ ❏ ❏ ❏ ❏
Strength training ❏ ❏ ❏ ❏ ❏
Functional fitness ❏ ❏ ❏ ❏ ❏
Cardio ❏ ❏ ❏ ❏ ❏
Other ❏ ❏ ❏ ❏ ❏