Annual screening questionnaire for health surveillance
SCREENING QUESTIONNAIRE FOR WORKERS USING HAND-HELD VIBRATING TOOLS, HAND-GUIDED VIBRATING MACHINES AND HAND-FED VIBRATING MACHINES
Date: ..................................................................................................
Employee Name: ..................................................................................
Occupation: .........................................................................................
Address: ..............................................................................................
Date of birth: .......................................................................................
National Insurance no: .........................................................................
Employer name: ...................................................................................
Date of previous screening: .................................................................
OCCUPATIONAL HISTORY
Dates Job Title
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Have you been using hand-held vibrating tools, machines or hand-fed processes in your job or, if this is a review, since your last assessment? Y/N (detail work history above)
If NO or more than two years since last exposure please return the form - there is no need to answer further questions.
If YES:
1 Do you have any numbness or tingling of the fingers lasting more than 20 minutes after using vibrating equipment? Y/N
2 Do you have numbness or tingling of the fingers at any other time? Y/N
3 Do you wake at night with pain, tingling or numbness in your hand or wrist? Y/N
4 Have any of your fingers gone white* on cold exposure? Y/N
5 Have you noticed any change in your response to your tolerance of working outdoors in the cold? Y/N
6 Are you experiencing any other problems in your hands or arms? Y/N
7 Do you have difficulty picking up very small objects, e.g. screws or buttons or opening tight jars? Y/N
8 Has anything changed about your health since the last assessment? Y/N
*Whiteness means a clear discoloration of the fingers with a sharp edge, usually followed by a red flush.
I certify that all the answers given above are true to the best of my knowledge and belief.
RETURN TO: ......................................................................................