Online Body Symptoms Survey

PDPA Notice: No personal data will be stored in our system when you generate this survey.

Survey Form Instruction:

1. Choose relevant choice on any body parts (Column A) if you feel discomfort/pain during your work in the last 12 months.
2. For those body parts you were feeling pain/discomfort, choose relevant choice (Column B) if in your opinion, the pain is due to work.

Body Part	Pain/Discomfort (A) L: Left   R: Right	Pain Due To Work? (B) L: Left   R: Right
Neck (A)	Yes No	Yes No
Shoulder (B)	Yes No	Yes No
Upper Back (C)	Yes No	Yes No
Upper Arm (D)	L R None	L R None
Elbow (E)	L R None	L R None
Lower Arm (F)	L R None	L R None
Wrist (G)	L R None	L R None
Hand (H)	L R None	L R None
Lower Back (I)	Yes No	Yes No
Thigh (J)	L R None	L R None
Knee (K)	L R None	L R None
Calf (L)	L R None	L R None
Ankle (M)	L R None	L R None
Feet (N)	L R None	L R None

Name:

Staff ID No.:

Department:

Job Tasks:

Contact No.:

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Date:

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