What is a symptoms survey for work-related musculoskeletal disorders (WMSDs)?
One element of an effective ergonomics program for the prevention of WMSDs is to ask workers questions about their health. A symptoms survey helps to find out when workers are experiencing any discomfort, pain or disability that may be related to workplace activities.
Sample Health Survey
1.
What is your current job title? __________________________
2.
What is your sex?
3.
How long have you been employed at your present job? _______________
4.
In this diagram the body parts are shown approximately. Please indicate where your pain or discomfort is located, if any. Shade in any area(s) where you have had pain or discomfort that lasted 2 days or more in the last year which was caused by your job. If you did not shade in any area, go to question #46.
5.
In the last year, have you had pain or discomfort caused by your job that lasted 2 days or more?
a) Neck
b) Shoulder
c) Elbow
d) Wrist/forearm
e) Hand
f) Upper back
g) Lower back
h) Foot
If you answered "no" to all of these questions, go to question #46. If you answered "yes" to any of the points in a-h above, please answer the following questions for that particular part(s) of the body.
Neck pain
6.
While working is the pain or discomfort:
7.
After your shift, is the pain or discomfort:
8.
After a week away from work, is the pain or discomfort:
9.
Has the pain or discomfort caused you to take time off work in the past year?
If yes, how many days off in all? _____ days
10.
To what degree has your pain or discomfort interfered with your work, your life outside of work, and your sleep in the past year?
1) How much does it interfere with your work?
If you had to take time off work, how many days off in the past year? _____
2) How much does it interfere with your life outside of work?
If you had to stop activity, how many days in the past year did you stop it? _____
3) How much does it interfere with your sleep?
Shoulder pain
11.
While working is the pain or discomfort:
12.
After your shift, is the pain or discomfort:
13.
After a week away from work, is the pain or discomfort:
14.
Has the pain or discomfort caused you to take time off work in the past year?
If yes, how many days off in all? _____ days
15.
To what degree has your pain or discomfort interfered with your work, your life outside of work, and your sleep in the past year?
1) How much does it interfere with your work?
If you had to take time off work, how many days off in the past year? _____
2) How much does it interfere with your life outside of work?
If you had to stop activity, how many days in the past year did you stop it? _____
3) How much does it interfere with your sleep?
Elbow pain
16.
While working is the pain or discomfort:
17.
After your shift, is the pain or discomfort:
18.
After a week away from work, is the pain or discomfort:
19.
Has the pain or discomfort caused you to take time off work in the past year?
If yes, how many days off in all? _____ days
20.
To what degree has your pain or discomfort interfered with your work, your life outside of work, and your sleep in the past year?
1) How much does if interfere with your work?
If you had to take time off work, how many days off in the past year? _____
2) How much does it interfere with your life outside of work?
If you had to stop activity, how many days in the past year did you stop it? _____
3) How much does it interfere with your sleep?
Wrist/forearm pain
21.
While working is the pain or discomfort:
22.
After your shift, is the pain or discomfort:
23.
After a week away from work, is the pain or discomfort:
24.
Has the pain or discomfort caused you to take time off work in the past year?
If yes, how many days off in all? _____ days
25.
To what degree has your pain or discomfort interfered with your work, your life outside of work, and your sleep in the past year?
1) How much does if interfere with your work?
If you had to take time off work, how many days off in the past year? _____
2) How much does it interfere with your life outside of work?
If you had to stop activity, how many days in the past year did you stop it? _____
3) How much does it interfere with your sleep?
Hand pain
26.
While working is the pain or discomfort:
27.
After your shift, is the pain or discomfort:
28.
After a week away from work, is the pain or discomfort:
29.
Has the pain or discomfort caused you to take time off work in the past year?
If yes, how many days off in all? _____ days
30.
To what degree has your pain or discomfort interfered with your work, your life outside of work, and your sleep in the past year?
1) How much does if interfere with your work?
If you had to take time off work, how many days off in the past year? _____
2) How much does it interfere with your life outside of work?
If you had to stop activity, how many days in the past year did you stop it? _____
3) How much does it interfere with your sleep?
Upper back pain
31.
While working is the pain or discomfort:
32.
After your shift, is the pain or discomfort:
33.
After a week away from work, is the pain or discomfort:
34.
Has the pain or discomfort caused you to take time off work in the past year?
If yes, how many days off in all? _____ days
35.
To what degree has your pain or discomfort interfered with your work, your life outside of work, and your sleep in the past year?
1) How much does if interfere with your work?
If you had to take time off work, how many days off in the past year? _____
2) How much does it interfere with your life outside of work?
If you had to stop activity, how many days in the past year did you stop it? _____
3) How much does it interfere with your sleep?
Lower back pain
36.
While working is the pain or discomfort:
37.
After your shift, is the pain or discomfort:
38.
After a week away from work, is the pain or discomfort:
39.
Has the pain or discomfort caused you to take time off work in the past year?
If yes, how many days off in all? _____ days
40.
To what degree has your pain or discomfort interfered with your work, your life outside of work, and your sleep in the past year?
1) How much does if interfere with your work?
If you had to take time off work, how many days off in the past year? _____
2) How much does it interfere with your life outside of work?
If you had to stop activity, how many days in the past year did you stop it? _____
3) How much does it interfere with your sleep?
Foot pain
41.
While working is the pain or discomfort:
42.
After your shift, is the pain or discomfort:
43.
After a week away from work, is the pain or discomfort:
44.
Has the pain or discomfort caused you to take time off work in the past year?
If yes, how many days off in all? _____ days
45.
To what degree has your pain or discomfort interfered with your work, your life outside of work, and your sleep in the past year?
1) How much does if interfere with your work?
If you had to take time off work, how many days off in the past year? _____
2) How much does it interfere with your life outside of work?
If you had to stop activity, how many days in the past year did you stop it? _____
3) How much does it interfere with your sleep?
46.
Do you experience any other health problems related to your work?
If yes, please describe
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