Computer Operator Symptoms Survey

Name:_______________________________________________________

Employer:____________________________________________________

Department: __________________________________________________

Work Location:_________________Work Phone #:___________________

E-Mail: __________________________________________________

Current Job:_______________________How Long:___________________

If less than 2 years in this position, previous job:________________________
How Long:_____________________

1. On average, how many hours a day do you work with a computer? 
   less than 2______   2-4 hours______  more than 4 hours______ 
   
2. During the past two years, have you had any of the following symptoms that lasted for at least a week  
   
   

   	YES	NO
   Pain, aches, stiffness, burning, numbness or tingling in your fingers, hands, orwrists?
   Pain, aches, stiffness, burning, numbness or tingling in the elbows, orforearms?
   Pain, aches, stiffness, burning, numbness or tingling in the shoulders?
   Pain, aches, stiffness, burning, numbness or tingling in your neck?
   Pain, aches, stiffness, burning, numbness or tingling in your back?

   
   
3. Are you currently feeling pain, aches, stiffness, burning, numbness or tingling in your: 
   
   

   	YES	NO
   a) fingers, hands, or wrists?
   b) elbows or forearms?
   c) shoulders?
   d) neck?
   e) back?

   
   
4. In the past two years, has a physician told you that you have any of the following conditions? 
    

   	YES	NO
   a) Carpal Tunnel Syndrome
   b) Tendinitis
   c) Tenosynovitis
   d) Ganglionic Cyst
   e) Bursitis
   f) Rotator cuff injury
   g) DeQuervain's Disease
   h) Epicondylitis

   
   
5. If you answered 'Yes' to any of the conditions in the previous question, for , if any, which did you file a workers' compensation claim? 
   a) ___ b) ___ c) ___ d) ___ e) ___ f) ___ 
   
6. In the past two years, have you ever been on restricted duty because you were injured or felt pains as the result of working with a computer? 
   YES________NO________ 
   
7. How many days of work have you missed in the last 12 months because of pain or injuries caused by working on a computer? 
   1 - 5 days____ 6 - 15 days_____ more than 15 days_____ 
   
8. Do you regularly get headaches while you work with a computer? 
   YES________NO________ 
   
   If you answered Yes to Question 8, how often do they occur?
     
   

   	YES	NO
   Once every 2 weeks?
   Once a week?
   More than once a week?
   Almost daily?

   
   
9. Do your eyes usually itch, burn, or feel tired after a day of working with your computer? 
   YES________NO________ 
   
10. Does your vision get blurred while you are working on your? 
    YES________NO________