Medical History Checklist: Symptoms Survey for Work-Related Musculoskeletal Disorders (WMSDs)
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What is a symptoms survey for work-related musculoskeletal disorders (WMSDs)?
Back to topOne 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 | |||
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1. | What is your current job title? __________________________ | ||
2. | What are your main work tasks? | ||
3. | How long have you been performing these tasks? | ||
4. | What is your main body/work position? | ||
5. | What are the tools you work with most often? | ||
6. | Do you often have to reach away from your body? | ||
7. | Do you often handle objects or tools above shoulder height or near the floor? | ||
8. | Do you do repetitive movements? | ||
9. | Among the tasks that you do, which ones do you find the most difficult? | ||
10. | Have there been any changes at work recently (job, tasks, tools)? | ||
11. |
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. |
Type of pain | |||
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5. | In the last year, have you had pain or discomfort caused by your job that lasted 2 days or more? | ||
a) Neck | Yes | No | |
b) Shoulder | Yes | No | |
c) Elbow | Yes | No | |
d) Wrist/forearm | Yes | No | |
e) Hand | Yes | No | |
f) Upper back | Yes | No | |
g) Lower back | Yes | No | |
h) Foot | Yes | No | |
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 | |||
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6. | While working is the pain or discomfort: | ||
Less | Same | Worse | |
7. | After your shift, is the pain or discomfort: | ||
Less | Same | Worse | |
8. | After a week away from work, is the pain or discomfort: | ||
Less | Same | Worse | |
9. | Has the pain or discomfort caused you to take time off work in the past year? | ||
Yes | No | ||
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? | |||
No interference | |||
Some interference | |||
Had to take time off work due to pain | |||
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? | |||
No interference | |||
Some interference | |||
Had to stop enjoying activities due to pain | |||
If you had to stop activities, how many days in the past year did you stop it? _____ | |||
3) How much does it interfere with your sleep? | |||
No interference | |||
Some interference | |||
It affects me every night |
Shoulder pain | |||
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11. | While working is the pain or discomfort: | ||
Less | Same | Worse | |
12. | After your shift, is the pain or discomfort: | ||
Less | Same | Worse | |
13. | After a week away from work, is the pain or discomfort: | ||
Less | Same | Worse | |
14. | Has the pain or discomfort caused you to take time off work in the past year? | ||
Yes | No | ||
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? | |||
No interference | |||
Some interference | |||
Had to take time off work due to pain | |||
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? | |||
No interference | |||
Some interference | |||
Had to stop enjoying activities due to pain | |||
If you had to stop activities, how many days in the past year did you stop it? _____ | |||
3) How much does it interfere with your sleep? | |||
No interference | |||
Some interference | |||
It affects me every night |
Elbow pain | |||
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16. | While working is the pain or discomfort: | ||
Less | Same | Worse | |
17. | After your shift, is the pain or discomfort: | ||
Less | Same | Worse | |
18. | After a week away from work, is the pain or discomfort: | ||
Less | Same | Worse | |
19. | Has the pain or discomfort caused you to take time off work in the past year? | ||
Yes | No | ||
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? | |||
No interference | |||
Some interference | |||
Had to take time off work due to pain | |||
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? | |||
No interference | |||
Some interference | |||
Had to stop enjoying activities due to pain | |||
If you had to stop activities, how many days in the past year did you stop it? _____ | |||
3) How much does it interfere with your sleep? | |||
No interference | |||
Some interference | |||
It affects me every night |
Wrist/forearm pain | |||
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21. | While working is the pain or discomfort: | ||
Less | Same | Worse | |
22. | After your shift, is the pain or discomfort: | ||
Less | Same | Worse | |
23. | After a week away from work, is the pain or discomfort: | ||
Less | Same | Worse | |
24. | Has the pain or discomfort caused you to take time off work in the past year? | ||
Yes | No | ||
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? | |||
No interference | |||
Some interference | |||
Had to take time off work due to pain | |||
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? | |||
No interference | |||
Some interference | |||
Had to stop enjoying activities due to pain | |||
If you had to stop activities, how many days in the past year did you stop it? _____ | |||
3) How much does it interfere with your sleep? | |||
No interference | |||
Some interference | |||
It affects me every night |
Hand pain | |||
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26. | While working is the pain or discomfort: | ||
Less | Same | Worse | |
27. | After your shift, is the pain or discomfort: | ||
Less | Same | Worse | |
28. | After a week away from work, is the pain or discomfort: | ||
Less | Same | Worse | |
29. | Has the pain or discomfort caused you to take time off work in the past year? | ||
Yes | No | ||
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? | |||
No interference | |||
Some interference | |||
Had to take time off work due to pain | |||
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? | |||
No interference | |||
Some interference | |||
Had to stop enjoying activities due to pain | |||
If you had to stop activities, how many days in the past year did you stop it? _____ | |||
3) How much does it interfere with your sleep? | |||
No interference | |||
Some interference | |||
It affects me every night |
Upper back pain | |||
---|---|---|---|
31. | While working is the pain or discomfort: | ||
Less | Same | Worse | |
32. | After your shift, is the pain or discomfort: | ||
Less | Same | Worse | |
33. | After a week away from work, is the pain or discomfort: | ||
Less | Same | Worse | |
34. | Has the pain or discomfort caused you to take time off work in the past year? | ||
Yes | No | ||
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? | |||
No interference | |||
Some interference | |||
Had to take time off work due to pain | |||
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? | |||
No interference | |||
Some interference | |||
Had to stop enjoying activities due to pain | |||
If you had to stop activities, how many days in the past year did you stop it? _____ | |||
3) How much does it interfere with your sleep? | |||
No interference | |||
Some interference | |||
It affects me every night |
Lower back pain | |||
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36. | While working, is the pain or discomfort: | ||
Less | Same | Worse | |
37. | After your shift, is the pain or discomfort: | ||
Less | Same | Worse | |
38. | After a week away from work, is the pain or discomfort: | ||
Less | Same | Worse | |
39. | Has the pain or discomfort caused you to take time off work in the past year? | ||
Yes | No | ||
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? | |||
No interference | |||
Some interference | |||
Had to take time off work due to pain | |||
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? | |||
No interference | |||
Some interference | |||
Had to stop enjoying activities due to pain | |||
If you had to stop activities, how many days in the past year did you stop it? _____ | |||
3) How much does it interfere with your sleep? | |||
No interference | |||
Some interference | |||
It affects me every night |
Foot pain | |||
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41. | While working is the pain or discomfort: | ||
Less | Same | Worse | |
42. | After your shift, is the pain or discomfort: | ||
Less | Same | Worse | |
43. | After a week away from work, is the pain or discomfort: | ||
Less | Same | Worse | |
44. | Has the pain or discomfort caused you to take time off work in the past year? | ||
Yes | No | ||
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? | |||
No interference | |||
Some interference | |||
Had to take time off work due to pain | |||
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? | |||
No interference | |||
Some interference | |||
Had to stop enjoying activities due to pain | |||
If you had to stop activities, how many days in the past year did you stop it? _____ | |||
3) How much does it interfere with your sleep? | |||
No interference | |||
Some interference | |||
It affects me every night |
Other health problems | ||
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46. | Do you experience any other health problems related to your work? | |
Yes No | ||
If yes, please describe: |
- Fact sheet last revised: 2020-02-07