Ergonomic Symptoms Survey Checklist

Employee Name: ____________________________________         Date: ___________________

Job Name or Workstation:  _______________________________________________________

Shift: __________        Hours worked/week: _____________ Time on THIS job: ________

Have you had any pain or discomfort during the last year? ______________________________

Check the areas:

Neck: [  ] Shoulder: [  ] Elbow/forearm: [  ] Hand/wrist: [  ] Fingers: [  ] Upper Back: [  ]

Lower Back: [  ] Thigh/knee: [  ] Low Leg [  ] Ankle/foot [  ]

Put a check by the word(s) that best describe your problem:

Aching: [  ] Burning: [  ] Cramping: [  ] Loss of Color: [  ] Numbness (asleep): [  ]

Pain: [  ] Swelling: [  ] Stiffness: [  ] Tingling: [  ] Weakness: [  ]

Other: ________________________________________________________________________

When did you first notice the problem? ______________________________________________

How long does each episode last? __________________________________________________

What do you think caused the problem? _____________________________________________

Have you had this problem in the last 7 days? _________________________________________

Have you had medical treatment for this problem? _____________________________________

If no, why not? _________________________________________________________________

If yes, where did you receive treatment? _____________________________________________

Did the treatment help? __________________________________________________________

How much time have you lost in the last year because of this problem? _____ days

Please comment on what you think would improve your symptoms: _______________________

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