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HAVS TIER 2 HEALTH SURVEILLANCE

Screening questionnaire for workers using hand held vibrating tools;

hand guided vibrating machines and handfed vibrating machines.

PART 1 – To be completed by the Employee

Birthday
Month
Day
Year

Please state ‘Yes or ‘No’ to the following questions:

1. Have you ever used handheld vibrating tools, machines or handfed processes in your job?
2. Do you have any tingling of the fingers lasting more than 20 minutes after using vibrating equipment?
3. Do you have tingling of the fingers any other time?
4. Do you wake at night with pain, tingling, or numbness in your hand or wrist?
5. Does one or more of your fingers go numb for more than 20 minutes after using vibrating equipment?
6. Have your fingers gone white* on cold exposure? *Whiteness means a clear discolouration of the fingers with a sharp edge, usually followed by a red flush (see picture below).
7. If ‘YES’ to Question 6. Do you have difficulty rewarming your hands when leaving the cold?
8. Do you fingers go white at any other time?
9. Are you experiencing any other problems with the muscles or joints of the hands or arms, e.g. pain, stiffness or swelling?
10. Do you have difficulty picking up very small objects, e.g. screws or buttons or opening tight jars?
11. Have you ever had a neck, arm or hand injury or operation?
12. Have you ever had any serious diseases of joints, skin, nerves, heart or blood vessels?
13. Are you on any long term medication?
Date
Month
Day
Year

PART 2 – to be completed by Occupational Health Nurse

Date
Month
Day
Year
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