Keele Form

This section is ONLY to be completed by people who have been referred to the Provide Physiotherapy Outpatients Service and have recently received contact from the service requesting to complete these additional questions in order to process your referral.

These 10 questions regarding your musculoskeletal problem that you have been referred for physiotherapy will provide essential information to assist the service in identifying the most appropriate level of care you need to manage your problem effectively.

Your answers will be linked to your current referral once you have submitted this online and you will be contacted by the service following a robust triage process to be informed of what level of care you require.

If you do not provide this additional information within 7 days of receiving contact from the service, your referral will not be able to be processed and will be returned to your referrer.

The Keele STarT MSK Tool © Self-report version

For question 1 - 9, think about just the last two weeks:
Pain intensity 1. On average, how intense was your pain? [where 0 is “no pain”, 10 is “pain as bad as it could be”]

Select one of the options for each question below	Yes	No
2. Do you often feel unsure about how to manage your pain condition?	Y	N
3. Over the last 2 weeks, have you been bothered a lot by your pain?	Y	N
4. Have you only been able to walk short distances because of your pain?	Y	N
5. Have you had troublesome joint or muscle pain in more than one part of your body?	Y	N
6. Do you think your condition will last a long time?	Y	N
7. Do you have other important health problems?	Y	N
8. Has a pain made you feel down or depressed in the last two weeks?	Y	N
9. Do you feel it is unsafe for a person with a condition like yours to be physically active?	Y	N
10. Have you had your current pain problem for 6 months or more?	Y	N

Forename*
Surname*
Email Address*
Date Of Birth*

Keele Form

Musculoskeletal Risk Stratification