Ambulance Victoria’s Functional Conditioning Program

Initial Assessment Consent

Full Name

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Your Location

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Email address

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Age

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Male

Female

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Mobile number

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Role

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Select your assessment date:

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Select your assessment time:

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Initial Assessment

Followup Assessment

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Medical History/Injuries

List any medical concerns/injuries here

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Current Exercise

List current exercise here

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What does the assessment involve?

During this assessment, you will be taken through a number of tests by the Health Professional that attempt to replicate some of the movements and activities you complete onsite

These tests will be used to identify where potential sources of injury may evolve from

You will then be given a personalised exercise program to be completed independently at home

The Health Professional will provide you with a handout that details your exercises

The Health Professional will meet with you to review your exercises on a fortnightly basis and progress them accordingly

You will be retested again in 8 weeks to assess for changes and improvements.

Why do I need to complete this assessment?

Injuries will often arise due to deficiencies in certain movements patterns, with these deficiencies often remaining hidden until an injury occurs

A functional assessment aims to identify such issues before they become a problem and result in an injury

By analysing certain movement patterns and functional tasks, the Health Professional is able to obtain a broader picture of how your body moves and then direct treatment to target any of these dysfunctions

What if I had never experienced an injury or have no pain?

If you have never experienced an injury or are not experiencing any pain At the moment, this does not mean that functional testing is not important for you

Often our body’s learn to move in ways to overcome weaknesses or deficiencies and although in the short term this may be helpful to complete the task at hand, long-term this is not ideal

Repetitive tasks and/or manual tasks often result in the small micro-tears in muscles and can create muscle imbalances

Although often not painful, it is these small tears or imbalances, that if not treated early, can manifest into more significant problems in the future

How is my information handled?

Healthworks will not share your functional assessment measurements with Ambulance Victoria on an individual level and only as part of a deidentified group to provide a high-level summary on the program.

The completion page document which is completed at the end of the program will be completed with the physio to provide feedback on the program.

Healthworks will use your mobile number to send automatic text message reminders throughout the program to assist with compliance and program engagement

Consent

I understand that my attendance in this program is voluntary. For operational reasons, I understand my manager will be aware of my attendance.

I am aware that the information captured in this assessment will be stored by Healthworks and any reporting will be deidentified group results, but not individual results, will be shared with my employer.

I consent to receiving weekly text messages from Healthworks to assist with compliance and program adherence

<h3>What does the assessment involve?</h3><br />
<ul><br />
	<li>During this assessment, you will be taken through a number of tests by the Health Professional that attempt to replicate some of the movements and activities you complete onsite</li><br />
	<li>These tests will be used to identify where potential sources of injury may evolve from</li><br />
	<li>You will then be given a personalised exercise program to be completed independently at home</li><br />
	<li>The Health Professional will provide you with a handout that details your exercises</li><br />
	<li>The Health Professional will meet with you to review your exercises on a fortnightly basis and progress them accordingly</li><br />
	<li>You will be retested again in 8 weeks to assess for changes and improvements.</li><br />
</ul><br />
<h3>Why do I need to complete this assessment?</h3><br />
<ul><br />
	<li>Injuries will often arise due to deficiencies in certain movements patterns, with these deficiencies often remaining hidden until an injury occurs</li><br />
	<li>A functional assessment aims to identify such issues before they become a problem and result in an injury</li><br />
	<li>By analysing certain movement patterns and functional tasks, the Health Professional is able to obtain a broader picture of how your body moves and then direct treatment to target any of these dysfunctions</li><br />
</ul><br />
<h3>What if I had never experienced an injury or have no pain?</h3><br />
<ul><br />
	<li>If you have never experienced an injury or are not experiencing any pain At the moment, this does not mean that functional testing is not important for you</li><br />
	<li>Often our body’s learn to move in ways to overcome weaknesses or deficiencies and although in the short term this may be helpful to complete the task at hand, long-term this is not ideal</li><br />
	<li>Repetitive tasks and/or manual tasks often result in the small micro-tears in muscles and can create muscle imbalances</li><br />
	<li>Although often not painful, it is these small tears or imbalances, that if not treated early, can manifest into more significant problems in the future</li><br />
</ul><br />
<h3>How is my information handled?</h3><br />
<ul><br />
	<li>Healthworks will not share your functional assessment measurements with Ambulance Victoria on an individual level and only as part of a deidentified group to provide a high-level summary on the program.</li><br />
	<li>The completion page document which is completed at the end of the program will be completed with the physio to provide feedback on the program.</li><br />
	<li>Healthworks will use your mobile number to send automatic text message reminders throughout the program to assist with compliance and program engagement</li><br />
</ul><br />
<h3>Consent</h3><br />
<ul><br />
	<li>I understand that my attendance in this program is voluntary. For operational reasons, I understand my manager will be aware of my attendance.</li><br />
	<li>I am aware that the information captured in this assessment will be stored by Healthworks and any reporting will be deidentified group results, but not individual results, will be shared with my employer.</li><br />
	<li>I consent to receiving weekly text messages from Healthworks to assist with compliance and program adherence</li><br />
</ul>

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Consent

I have read and understood the above

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Date

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Thoracic Rotation Flexibility Test

Left Thoracic Rotation

Hand and shoulder are touching the floor while knees are together (less than 5cm apart) and not lifting from the floor

Only hand is touching the floor while knees together and not lifting from the floor (less than 5cm apart)

Neither hand nor shoulder touching the floor

Unable to complete

Field is required!

Right Thoracic Rotation

Hand and shoulder are touching the floor while knees are together (less than 5cm apart) and not lifting from the floor

Only hand is touching the floor while knees together and not lifting from the floor (less than 5cm apart)

Neither hand nor shoulder touching the floor

Unable to complete

Field is required!

Observations/Comments:

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Rating	Movement
Good (4)	Hand and shoulder are touching the floor while knees are together (less than 5cm apart) and not lifting from the floor
Average (3)	Only hand is touching the floor while knees together and not lifting from the floor (less than 5cm apart)
Below Average (2)	Neither hand nor shoulder touching the floor

<table border="1" width="80%" cellspacing="0" cellpadding="5" height="50">
	<tr>
		<td width="15%" bgcolor="#282661" valign="bottom"><b><font color="#FFFFFF">Rating</font></b></td>
		<td width="82%" bgcolor="#282661"><font color="#FFFFFF">Movement</font></td>
	</tr>
	<tr>
		<td width="15%">Good (4)</td>
		<td width="82%">Hand and shoulder are touching the floor while knees are together (less than 5cm apart) and not lifting from the floor</td>
	</tr>
	<tr>
		<td width="15%">Average (3)</td>
		<td width="82%">Only hand is touching the floor while knees together and not lifting from the floor (less than 5cm apart)</td>
	</tr>
	<tr>
		<td width="15%">Below Average (2)</td>
		<td width="82%">Neither hand nor shoulder touching the floor</td>
	</tr>
	</table>

Field is required!

7 Stage Abdominal Strength Test

Unable to perform Stage 1

Stage 1: With arms extended, employee curls up so that wrists reach the knees

Stage 2: With arms extended, employee curls up so that the elbows reach the knees

Stage 3: With the arms held together across abdominals, employee curls up so that the chest touches the thighs

Stage 4: With arms held across the chest holding the shoulders, employee curls up so that the forearms touches the thighs

Stage 5: With hands held behind the head, employee curls up so that the chest touches the thighs

Stage 6&7: As per stage 5, with a 2.5 kg weight held behind head and chest touches the thigh. Repeat with 5kg if successful for stage 7

Field is required!

Observations/Comments:

Field is required!

Rating	Level	Score
Excellent (6)	Stage 6 & 7	As per stage 5, with a 2.5 kg weight held behind head and chest touches the thigh. Repeat with 5kg if successful for stage 7
Very good (5)	Stage 5	With hands held behind the head, employee curls up so that the chest touches the thighs
Good (4)	Stage 4	With arms held across the chest holding the shoulders, employee curls up so that the forearms touches the thighs
Average (3)	Stage 3	With the arms held together across abdominals, employee curls up so that the chest touches the thighs
Below Average (2)	Stage 2	With arms extended, employee curls up so that the elbows reach the knees
Poor (1)	Stage 1	With arms extended, employee curls up so that wrists reach the knees
Very poor (0)	-	Unable to perform Stage 1

<table border="1" width="80%" cellspacing="0" cellpadding="5" height="50">
	<tr>
		<td width="15%" bgcolor="#282661" valign="bottom"><b><font color="#FFFFFF">Rating</font></b></td>
		<td width="10%" bgcolor="#282661"><font color="#FFFFFF"><b>Level</b></font></td>
		<td width="72%" bgcolor="#282661"><font color="#FFFFFF"><b>Score</b></font></td>
	</tr>
	<tr>
		<td width="15%">Excellent (6)</td>
		<td width="10%">Stage 6 & 7</td>
		<td width="72%">As per stage 5, with a 2.5 kg weight held behind head and chest touches the thigh.  Repeat with 5kg if successful for stage 7</td>
	</tr>
	<tr>
		<td width="15%">Very good (5)</td>
		<td width="10%">Stage 5</td>
		<td width="72%">With hands held behind the head, employee curls up so that the chest touches the thighs</td>
	</tr>
	<tr>
		<td width="15%">Good (4)</td>
		<td width="10%">Stage 4</td>
		<td width="72%">With arms held across the chest holding the shoulders, employee curls up so that the forearms touches the thighs</td>
	</tr>
	<tr>
		<td width="15%">Average (3)</td>
		<td width="10%">Stage 3</td>
		<td width="72%">With the arms held together across abdominals, employee curls up so that the chest touches the thighs</td>
	</tr>
	<tr>
		<td width="15%">Below Average (2)</td>
		<td width="10%">Stage 2</td>
		<td width="72%">With arms extended, employee curls up so that the elbows reach the knees</td>
	</tr>
	<tr>
		<td width="15%">Poor (1)</td>
		<td width="10%">Stage 1</td>
		<td width="72%">With arms extended, employee curls up so that wrists reach the knees</td>
	</tr>
	<tr>
		<td width="15%">Very poor (0)</td>
		<td width="10%">-</td>
		<td width="72%">Unable to perform Stage 1</td>
	</tr>
</table>

<table border="1" width="80%" cellspacing="0" cellpadding="5" height="50">
	<tr>
		<td width="15%" bgcolor="#282661" valign="bottom"><b><font color="#FFFFFF">Rating</font></b></td>
		<td width="10%" bgcolor="#282661"><font color="#FFFFFF"><b>Level</b></font></td>
		<td width="72%" bgcolor="#282661"><font color="#FFFFFF"><b>Score</b></font></td>
	</tr>
	<tr>
		<td width="15%">Excellent (6)</td>
		<td width="10%">Stage 6 & 7</td>
		<td width="72%">As per stage 5, with a 2.5 kg weight held behind head and chest touches the thigh.  Repeat with 5kg if successful for stage 7</td>
	</tr>
	<tr>
		<td width="15%">Very good (5)</td>
		<td width="10%">Stage 5</td>
		<td width="72%">With hands held behind the head, employee curls up so that the chest touches the thighs</td>
	</tr>
	<tr>
		<td width="15%">Good (4)</td>
		<td width="10%">Stage 4</td>
		<td width="72%">With arms held across the chest holding the shoulders, employee curls up so that the forearms touches the thighs</td>
	</tr>
	<tr>
		<td width="15%">Average (3)</td>
		<td width="10%">Stage 3</td>
		<td width="72%">With the arms held together across abdominals, employee curls up so that the chest touches the thighs</td>
	</tr>
	<tr>
		<td width="15%">Below Average (2)</td>
		<td width="10%">Stage 2</td>
		<td width="72%">With arms extended, employee curls up so that the elbows reach the knees</td>
	</tr>
	<tr>
		<td width="15%">Poor (1)</td>
		<td width="10%">Stage 1</td>
		<td width="72%">With arms extended, employee curls up so that wrists reach the knees</td>
	</tr>
	<tr>
		<td width="15%">Very poor (0)</td>
		<td width="10%">-</td>
		<td width="72%">Unable to perform Stage 1</td>
	</tr>
</table>

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Your Functional Movement Score

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Individual scores

Shoulder Mobility

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Unable to complete exercise with LEFT Shoulder

<p>Unable to complete exercise with LEFT Shoulder</p>

Field is required!

Unable to complete exercise with RIGHT Shoulder

<p>Unable to complete exercise with RIGHT Shoulder</p>

Field is required!

Overhead Squat

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Unable to complete Overhead Squat exercise

<p>Unable to complete Overhead Squat exercise</p>

Field is required!

Sit and Reach

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Unable to complete Sit and Reach exercise

<p>Unable to complete Sit and Reach exercise</p>

Field is required!

Thoracic Rotation

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Unable to complete LEFT Thoracic exercise

<p>Unable to complete LEFT Thoracic exercise</p>

Field is required!

Unable to complete RIGHT Thoracic exercise

<p>Unable to complete RIGHT Thoracic exercise</p>

Field is required!

Ab Strength

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Unable to complete Abdominal Strength exercise

<p>Unable to complete Abdominal Strength exercise</p>

Field is required!

Push up Test

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Unable to complete Push Up exercise

<p>Unable to complete Push Up exercise</p>

Field is required!

Step Test

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Unable to complete Step exercise

<p>Unable to complete Step exercise</p>

Field is required!

Submit

Rating	Left (upper arm)	Right (upper arm)
Very good (5)	Fingers are overlapping by more than 5 cm	Fingers are overlapping by more than 5 cm
Good (4)	Fingers are overlapping up to 5 cm	Fingers are overlapping up to 5 cm
Average (3)	Fingers are touching	Fingers are touching
Below Average (2)	Fingertips are not touching but less than 5 cm apart.	Fingertips are not touching but less than 5 cm apart.
Poor (1)	Fingertips are greater than 5cm apart.	Fingertips are greater than 5cm apart.

Movement	Score
Feet 10 cm from wall with perfect execution and no compensation	Good (2)
When compensating at 10 cm mark. Perfect execution and no compensation at 20 cm mark	Average (1)
Compensating at 20 cm mark – let them try movement at 30 cm mark	Below Average (0)

Rating	Male Aged: 18-25
Excellent (6)	> 54 cm
Very good (5)	53-49 cm
Good (4)	48-44 cm
Average (3)	43-39 cm
Below Average (2)	38-34 cm
Poor (1)	33-29 cm
Very Poor (0)	<28 cm

Rating	Male Aged: 26-35
Excellent (6)	> 49 cm
Very good (5)	48-44 cm
Good (4)	43-42 cm
Average (3)	41-37 cm
Below Average (2)	36-31 cm
Poor (1)	30-24 cm
Very Poor (0)	<23 cm

Rating	Male Aged: 36-45
Excellent (6)	> 49cm
Very good (5)	48-44 cm
Good (4)	43-39 cm
Average (3)	38-34 cm
Below Average (2)	33-29 cm
Poor (1)	28-19 cm
Very Poor (0)	<18 cm

Ambulance Victoria’s Functional Conditioning Program

Initial Assessment Consent

What does the assessment involve?

Why do I need to complete this assessment?

What if I had never experienced an injury or have no pain?

How is my information handled?

Consent

Shoulder Mobility

Overhead Squat test

Compensations observed

Sit and Reach Test

Thoracic Rotation Flexibility Test

7 Stage Abdominal Strength Test

Push up and modified push up test

YMCA 3-minute step test

Individual scores

Rating	Female Aged: 15-19	Female Aged: 20-29	Female Aged: 30-39	Female Aged: 40-49	Female Aged: 50-59	Female Aged: 60-69
Excellent (6)	> 33	> 30	> 27	> 24	> 21	> 17
Very good (5)	25-32	21-29	20-26	15-23	11-20	12-16
Good (4)	18-24	15-20	13-19	11-14	7-10	5-11
Average (3)	12-17	10-14	8-12	5-10	2-6	2-4
Below Average (2)	< 11	< 9	< 7	< 4	< 1	< 1