Staff detail

Date
Salutation e.g. Mr/Dr/Miss
Marital status
Surname
First name
Date of birth
Age
Address
Job title

Staff Number:
Station/base
Contact number

Email address
GP surgery details
At work status
Have you referred to the Staying Well Service before
Yes No

Line manager (physio only)

Physiotherapy

If your referral relates to physio please complete the following information. Please note that the entitlement to physio is one referral per 12 months on a rolling basis:

Did the injury occur at work / whilst performing duties?

Yes No
Is the injury work related?
Work related Work exacerbated Not work related

Have you had this injury/complain before?

Yes No Unsure

Date of injury:
Has an incident report been completed
Yes No

Referral details

Are you a Serving or former Armed Forces member, or a dependent of a serving or former Armed Services Member?
Yes No

Please give details on the reason for referral into the Staying Well Service?

Self assessment - REFERRER to complete

On a scale of 1 to 10 (1 being the least and 10 the most) how much would you say the issue is impacting on your work life? Tick the appropriate number
1 2 3 4 5 6 7 8 9 10
On a scale of 1 to 10 (1 being the least and 10 the most) how much would you say the issue is impacting on your personal life? Tick the appropriate number
1 2 3 4 5 6 7 8 9 10
Are you currently off sick?
Yes No
Do you currently feel you are a risk to yourself?
Yes No
Do you currently feel you are a risk to others?
Yes No
Do you currently feel you are at risk from others?
Yes No
Have you discussed this risk with anyone?
Yes No
If so who? (GP, Line Manager, OH)

About you (if details different from above)

First name
Surname
Contact number
Email address
Relationship to staff member (if not yourself)

COVID-19

Are you presenting any symptoms:

A new continuous cough (persistent throughout the day and night):

A high temperature (of 37.8 degrees centigrade or higher):

Have you be disproportionately impacted by covid, for example have you been shielding or from a BAME background or have a disability or a carer or any other negative impact on your life through the covid pandemic?

YesNo