Please answer the following questions to express your interest in the
ESCAPE-pain programme. Please note, completion of this
questionnaire does not guarantee you a place on the programme.

Question Title

* 1. Full name 

Question Title

* 2. Date of birth

Date

Question Title

* 3. Email address

Question Title

* 4. Phone number

Question Title

* 5. Where did you hear about the ESCAPE-pain programme? (Please list surgery/hospital and
name of clinician if known)

Question Title

* 6. I can confirm, I am aged 45 years or older 

Question Title

* 7. I have had chronic joint pain for at least 3 months

Question Title

* 8. I require a supervised exercise programme 

Question Title

* 9. I am independently mobile and able to carry out regular exercise

Question Title

* 10. I am available to attend 2 weekly classes for 6 weeks

Question Title

* 11. I am able to communicate in English without an interpreter, in a group setting

Question Title

* 12. Please indicate where you are experiencing joint pain (please tick all that apply)

Medical screening

Question Title

* 13. Has your doctor ever said you have a heart condition or high blood pressure?

Question Title

* 14. Do you feel pain in your chest at rest, during your activities of daily living or when you do
physical activity?

Question Title

* 15. Do you lose balance because of dizziness, or have you lost consciousness in the past 12
months? Please answer no if your dizziness was associated with over breathing (including
during vigorous physical activity) 

Question Title

* 16. Have you ever been diagnosed with a chronic medical condition (other than heart disease or
high blood pressure)?

Question Title

* 17. Are you currently taking prescribed medication for a chronic medical condition?

Question Title

* 18. Do you currently have (or have had within the past 12 months), a bone, joint or soft tissue
(muscle, ligament, or tendon) that could be made worse by becoming physically active?
Please answer no if you have had a problem in the past but it does not limit your current
ability to be physically active. 

Question Title

* 19. Has your doctor ever said you should only do medically supervised physical activity? 

Declaration

Question Title

* 20. By joining the ESCAPE-pain programme, I consent to participate in a group class. I
understand confidential information may be shared during the programme and I agree to
keep the information strictly between ESCAPE-pain programme participants.

T