Pre-assessment questionnaire

About you
Your name*
First Last
Your email*
Phone number*
Job title*
About the company
Company name*
Company address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code
Managers name*
First Last
Managers email*
About your job role
Hours of work*
Place of work & main duties*
Please give us as many details as possible about what your job entails and the environment in which you work.
What does your current workstation look like?
Accepted file types: jpg, jpeg, png, gif.
Please post a photo if possible
Medical background
Height*
Weight*
In the case of DSE chairs, most are built around a mechanism designed to support a user weighing between 7.5 and 23.5 stone (~47.5 – ~150kg) and warrantied accordingly. If you do not wish to disclose your exact weight, we would be grateful if you would indicate whether you are inside/outside of those parameters.
Medical complaints or conditions*
Please explain why you have been referred to us for an assessment, as much information as possible is really useful, so if you could explain the issue, the history and what the impact on your work has been. Please feel free to type as much as you want in this area.
Time off work in the last two years?
What is your current stress level?
Think about home and work and give us a brief summary of how you are feeling. For instance, have you changed job recently?
Permission to discuss this report with your employer*
- Yes
- No
Comments
This field is for validation purposes and should be left unchanged.

About you