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

What is a symptoms survey for work-related musculoskeletal disorders (WMSDs)?

One 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
1.What is your current job title?    __________________________
2.What is your sex?     Male Male    Female Female
3.How long have you been employed at your present job? _______________
4.

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.

Diagram of body
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 YesNo No
     b) Shoulder Yes YesNo No
     c) ElbowYes YesNo No
     d) Wrist/forearmYes YesNo No
     e) HandYes YesNo No
     f) Upper backYes YesNo No
     g) Lower backYes YesNo No
     h) FootYes YesNo 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 LessSame SameWorse Worse
7.After your shift, is the pain or discomfort:
 Less LessSame SameWorse Worse
8.After a week away from work, is the pain or discomfort:
 Less LessSame SameWorse Worse
9.Has the pain or discomfort caused you to take time off work in the past year?
 Yes YesNo 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 No interference
      Some interference Some interference
      Had to take time off work 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 No interference
      Some interference Some interference
      Had to stop enjoying activity Had to stop enjoying activity due to pain
   If you had to stop activity, how many days in the past year did you stop it? _____
   
  3) How much does it interfere with your sleep?
      No interference No interference
      Some interference Some interference
     It affects me every night It affects me every night
Shoulder pain
11.While working is the pain or discomfort:
 Less LessSame SameWorse Worse
12.After your shift, is the pain or discomfort:
 Less LessSame SameWorse Worse
13.After a week away from work, is the pain or discomfort:
 Less LessSame SameWorse Worse
14.Has the pain or discomfort caused you to take time off work in the past year?
 Yes YesNo 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 No interference
      Some interference Some interference
      Had to take time off work 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 No interference
      Some interference Some interference
      Had to stop enjoying activity Had to stop enjoying activity due to pain
  If you had to stop activity, how many days in the past year did you stop it? _____
   
  3) How much does it interfere with your sleep?
      No interference No interference
      Some interference Some interference
      It affects me every night It affects me every night
Elbow pain
16.While working is the pain or discomfort:
 Less LessSame SameWorse Worse
17.After your shift, is the pain or discomfort:
 Less LessSame SameWorse Worse
18.After a week away from work, is the pain or discomfort:
 Less LessSame SameWorse Worse
19.Has the pain or discomfort caused you to take time off work in the past year?
 Yes YesNo 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 No interference
      Some interference Some interference
      Had to take time off work 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 No interference
      Some interference Some interference
      Had to stop enjoying activity Had to stop enjoying activity due to pain
  If you had to stop activity, how many days in the past year did you stop it? _____
   
  3) How much does it interfere with your sleep?
      No interference No interference
      Some interference Some interference
     It affects me every night It affects me every night
Wrist/forearm pain
21.While working is the pain or discomfort:
 Less LessSame SameWorse Worse
22.After your shift, is the pain or discomfort:
 Less LessSame SameWorse Worse
23.After a week away from work, is the pain or discomfort:
 Less LessSame SameWorse Worse
24.Has the pain or discomfort caused you to take time off work in the past year?
 Yes YesNo 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 No interference
      Some interference Some interference
      Had to take time off work 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 No interference
      Some interference Some interference
      Had to stop enjoying activity Had to stop enjoying activity due to pain
  If you had to stop activity, how many days in the past year did you stop it? _____
   
  3) How much does it interfere with your sleep?
      No interference No interference
      Some interference Some interference
      It affects me every night It affects me every night
Hand pain
26.While working is the pain or discomfort:
 Less LessSame SameWorse Worse
27.After your shift, is the pain or discomfort:
 Less LessSame SameWorse Worse
28.After a week away from work, is the pain or discomfort:
 Less LessSame SameWorse Worse
29.Has the pain or discomfort caused you to take time off work in the past year?
 Yes YesNo 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 No interference
      Some interference Some interference
      Had to take time off work 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 No interference
      Some interference Some interference
      Had to stop enjoying activity Had to stop enjoying activity due to pain
  If you had to stop activity, how many days in the past year did you stop it? _____
   
  3) How much does it interfere with your sleep?
      No interference No interference
      Some interference Some interference
      It affects me every night It affects me every night
Upper back pain
31.While working is the pain or discomfort:
 Less LessSame SameWorse Worse
32.After your shift, is the pain or discomfort:
 Less LessSame SameWorse Worse
33.After a week away from work, is the pain or discomfort:
 Less LessSame SameWorse Worse
34.Has the pain or discomfort caused you to take time off work in the past year?
 Yes YesNo 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 No interference
      Some interference Some interference
      Had to take time off work 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 No interference
      Some interference Some interference
      Had to stop enjoying activity Had to stop enjoying activity due to pain
  If you had to stop activity, how many days in the past year did you stop it? _____
   
  3) How much does it interfere with your sleep?
      No interference No interference
      Some interference Some interference
      It affects me every night It affects me every night
Lower back pain
36.While working is the pain or discomfort:
 Less LessSame SameWorse Worse
37.After your shift, is the pain or discomfort:
 Less LessSame SameWorse Worse
38.After a week away from work, is the pain or discomfort:
 Less LessSame SameWorse Worse
39.Has the pain or discomfort caused you to take time off work in the past year?
 Yes YesNo 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 No interference
      Some interference Some interference
      Had to take time off work 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 No interference
      Some interference Some interference
      Had to stop enjoying activity Had to stop enjoying activity due to pain
  If you had to stop activity, how many days in the past year did you stop it? _____
   
  3) How much does it interfere with your sleep?
      No interference No interference
      Some interference Some interference
     It affects me every night It affects me every night
Foot pain
41.While working is the pain or discomfort:
 Less LessSame SameWorse Worse
42.After your shift, is the pain or discomfort:
 Less LessSame SameWorse Worse
43.After a week away from work, is the pain or discomfort:
 Less LessSame SameWorse Worse
44.Has the pain or discomfort caused you to take time off work in the past year?
 Yes YesNo 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 No interference
      Some interference Some interference
      Had to take time off work 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 No interference
      Some interference Some interference
      Had to stop enjoying activity Had to stop enjoying activity due to pain
  If you had to stop activity, how many days in the past year did you stop it? _____
   
  3) How much does it interfere with your sleep?
      No interference No interference
      Some interference Some interference
     It affects me every night It affects me every night
Other health problems
46.Do you experience any other health problems related to your work?
 Yes Yes       No No
 If yes, please describe:





Document last updated on November 7, 2003
Document confirmed current on October 7, 2013

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