Ergonomic Symptoms Survey Checklist

1 Ergonomic Symptoms Survey ChecklistEmployee 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?

2 _____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? _____ daysPlease comment on what you think would improve your Symptoms : _____