HAVS - initial screening questionnaire

MEDICAL IN CONFIDENCE

INITIAL SCREENING QUESTIONNAIRE FOR WORKERS USING HAND-HELD VIBRATING TOOLS, HAND-GUIDED VIBRATING MACHINES AND HANDFED VIBRATING MACHINES

Date: ......................................................................................................................

Employee Name: ....................................................................................................

Occupation: .............................................................................................................

Address: ..................................................................................................................

Date of birth: ...........................................................................................................

National Insurance no: ............................................................................................

Employer Name: .....................................................................................................

Have you ever used hand-held vibrating tools, machines or hand-fed processes in your job? Y/N.

If YES:

(a) list year of first exposure ___________ and

(b) when you last used them ____________ (detail work history overleaf)

1 Do you have any tingling of the fingers lasting more than 20 minutes after using vibrating equipment? Y/N

2 Do you have 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 Do one or more of your fingers go numb more than 20 minutes after using vibrating equipment? Y/N

5 Have your fingers gone white* on cold exposure? Y/N

*Whiteness means a clear discoloration of the fingers with a sharp edge, usually followed by a red flush.

6 If Yes to 5, do you have difficulty re-warming them when leaving the cold? Y/N

7 Do your fingers go white at any other time? Y/N

8 Are you experiencing any other problems with the muscles or joints of the hands or arms? Y/N

9 Do you have difficulty picking up very small objects, e.g. screws or buttons or opening tight jars? Y/N

10 Have you ever had a neck, arm or hand injury or operation? Y/N

If so, give details................................................................................

11 Have you ever had any serious diseases of joints, skin, nerves, heart or blood vessels? Y/N. If so, give details...............................................................................

12 Are you on any long-term medication? Y/N

If so, give details __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

OCCUPATIONAL HISTORY

Dates Job Title

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