MUSCULOSKELETAL QUESTIONNAIRE

This questionnaire is adapted from HSE (Health and Safety Executive) advice and asks about any musculoskeletal disorders you may have recently experienced. This includes aches, or pains. Use the tick boxes to answer each of the fours questions for each part of the body mentioned below. The areas of the body are not sharply defined and some parts overlap. You should decide for yourself which part (if any) is or has been affected. Please make sure you put one tick only for each question. For example, you could answer ‘YES’ for the right elbow, or the left elbow, or both elbows. Positive responses may require further review by occupational health.

Have you at any time during the last 3 months had trouble (such as aches,

pain, discomfort, pins and needles, numbness or tingling) in the following:

Have you had this trouble during the last 7 days?

During the last 3 months has this trouble prevented

you carrying out normal activities

During the last 3 months has this trouble been caused or made worse by

your job?

EMPLOYEE DECLARATION

I confirm that the answers I have given are true to the best of my knowledge.