Employee Discomfort Survey

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* 1. Years on this job:

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* 2. Have you had any pain or discomfort during the last year that you feel could be job related?

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* 3. If you answered YES to Q2 please rate the level of discomfort over the last MONTH by checking off the
Box(es) that apply to you using the scale of 0 to 10, with 0 being no discomfort and 10 being the worst discomfort ever.

  0 - No Discomfort 1 2 3 4 5 6 7 8 9 10 - Worst Discomfort Ever
Neck
Left Shoulder
Left Elbow/Forearm
Left Wrist/Hand
Left Hip/Thigh/Buttock
Left Knee
Left Ankle/Foot
Right Shoulder
Right Elbow/Forearm
Upper Back
Lower Back
Right Wrist/Hand
Right Hip/Thigh/Buttock
Right Knee
Right Ankle/Foot

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* 4. When did you first notice your pain/discomfort?

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* 5. What do you think caused the discomfort?

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* 6. Please comment on what you think would help to reduce your level of discomfort.

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* 7. Do you consider your discomfort to be a ‘problem’?

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* 8. Do you find your discomfort affecting your work?

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* 9. Have you received medical treatment (doctor, chiropractor, physiotherapist, massage therapist, etc.) for your discomfort?

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* 10. Have you taken time off work as a result of your discomfort (vacation, sick days, lost time claim, medical aid, etc.)?

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