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Ergonomic Comfort Survey
* Indicates required question
Email
*
Your email
Name:
*
Your answer
Date:
*
MM
/
DD
/
YYYY
Occupation:
*
Your answer
Hours worked per week:
*
Your answer
What is your most common shift =?
*
Day
Night
Time working in present position (years and months)
*
Your answer
Total time working in your occupation (years and months)
*
Your answer
Have you had any discomfort during the last year? (If not, stop here.)
*
Yes
No
Please check the location(s) of discomfort during the past year.
Neck
Shoulder
Left Elbow
Right Elbow
Left Forearm
Right Forearm
Left Hand
Right Hand
Left Wrist
Right Wrist
Left Fingers
Right Fingers
Upper Back
Middle Back
Lower Back
Left Thigh
Right Thigh
Left Knee
Right Knee
Left Leg (below knee)
Right Leg (below knee)
Left Ankle
Right Ankle
Left Foot
RIght Foot
Please check the location(s) of discomfort currently.
Neck
Shoulder
Left Elbow
Right Elbow
Left Forearm
Right Forearm
Left Hand
Right Hand
Left Wrist
Right Wrist
Left Fingers
Right Fingers
Upper Back
Middle Back
Lower Back
Left Thigh
Right Thigh
Left Knee
Right Knee
Left Leg (below knee)
Right Leg (below knee)
Left Ankle
Right Ankle
Left Foot
RIght Foot
Please describe your discomfort in the area(s) checked.
Aching (soreness)
Numbness
Pins and Needles (tingling)
Burning
Pain
Cramping
Swelling
Stiffness
Other:
Please rate your discomfort in severity.
Very Mild
1
2
3
4
5
Intolerable
Clear selection
When did you notice the discomfort?
Your answer
When was the most recent occurrence of your discomfort?
Today
Several days ago
Weeks ago
Months ago
Year ago
Clear selection
Is discomfort intermittent or constant?
Intermittent
Constant
Clear selection
How many separate episodes of discomfort in the last year?
Your answer
What do you think caused your discomfort?
Your answer
Have you had medical treatment for your discomfort?
Yes
No
Clear selection
If not, do you plan to have medical treatment for your discomfort?
Yes
No
Clear selection
Has your condition affected how you perform your job?
Yes
No
Clear selection
Has experienced loss in range of motion, weakness, or numbness?
Yes
No
Clear selection
Do any of your hobbies or sports cause the same discomfort?
Yes
No
Clear selection
If yes, which ones:
Your answer
Please comment on what you think would ease or eliminate your discomfort at work.
Your answer
Thanks for completing our comfort survey. After completing the survey, please email us at
wearelavoro@gmail.com
to alert us of this.
(CBES Ergonomic Comfort Survey
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