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

Sample Health Survey
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
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?
	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
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
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
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
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
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
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
46.	Do you experience any other health problems related to your work?
	Yes No
	If yes, please describe:

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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)?