Medical History Checklist: Symptoms Survey for Work-Related Musculoskeletal Disorders (WMSDs)

One element of an effective ergonomics program for the prevention of WMSDs is asking workers questions about their health. A symptoms survey helps to determine when workers are experiencing any discomfort, pain, or disability that may be related to workplace activities.

Type of pain
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
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?
	a) 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? _____
	b) 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? _____
	c) How much does it interfere with your sleep?
	No interference
	Some interference
	It affects me every night

Shoulder pain
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?
	a) 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? _____
	b) 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? _____
	c) How much does it interfere with your sleep?
	No interference
	Some interference
	It affects me every night

Elbow pain
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?
	a) 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? _____
	b) 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? _____
	c) How much does it interfere with your sleep?
	No interference
	Some interference
	It affects me every night

Wrist/forearm pain
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?
	a) 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? _____
	b) 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? _____
	c) How much does it interfere with your sleep?
	No interference
	Some interference
	It affects me every night

Hand pain
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
2	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?
	a) 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? _____
	b) 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? _____
	c) 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?
	a) 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? _____
	b) 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? _____
	c) How much does it interfere with your sleep?
	No interference
	Some interference
	It affects me every night

Lower back pain
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?
	a) 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? _____
	b) 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? _____
	c) How much does it interfere with your sleep?
	No interference
	Some interference
	It affects me every night

Foot pain
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?
	a) 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? _____
	b) 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? _____
	c) How much does it interfere with your sleep?
	No interference
	Some interference
	It affects me every night

Other health issues
46	Do you experience any other health issues related to your work?
	Yes       No
	If yes, please describe: