HAND ARM VIBRATION ASSESSMENT QUESTIONNAIRE
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- Erick Poole
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1 Please complete and bring this questionnaire with you to your appointment: Surname: Frist Name Company: HAVS Screen date: Date of Birth: Male / Female: Job Title: What was your previous occupation? Name of previous employer(s) Date commenced current job? CUENT WOK Describe your job and its different tasks Write below each Power Driven tool you use: ist All Equipment Used Tick Use of each tool in Minutes or Hours per Day MEDICA HISTOY Are you a smoker Are you a non-smoker Are you a ex-smoker If an ex-smoker, when did you stop? Have you ever had a neck/arm/hand injury or operation? If so what and when? Are there any residual symptoms or deformities? Have you ever had any serious disease of the: Joints If so give details: Skin Nerves Heart/blood vessels Other Opus Health td. Company egistration.: egistered Offi ce: Burton Sweet, Cornerstone House, Midland Way, Thornbury Bristol BS35 2BS
2 Are you on any long-term medication or treatment for any condition? If so what and when? HAND SYMPTOMS Have you every suffered from your fi ngers going white on exposure to cold? If yes, is it continuous episodic When did you fi rst notice this? If you suffer now, how often does it occur? Several times a year? Several times a month? Several times a day? Every day? Does it occur in winter only? Winter and Summer? State most common circumstances: When did you fi rst notice this? Are you right handed or left handed? left handed? rigth handed? eading hand: Which hand do you notice vibration most? NUMBNESS Do your fingers go numb? Whilst working In response to cold? With blanching? At other times? If at other times what circumstances? Opus Health td. Company egistration.: egistered Offi ce: Burton Sweet, Cornerstone House, Midland Way, Thornbury Bristol BS35 2BS
3 BANCHING Blanching reported Blanching witnessed EFT HAND IGHT HAND Digit Total Th Digit Th Total TINGING (excluding transient tingling after using a vibrating tool) Do you have tingling in the fingers? Whilst working In response to cold? Do you get pain when your fi ngers warm up again? If yes, how long does it take for this pain to settle down? At other times? When did you fi rst notice this? Opus Health td. Company egistration.: egistered Offi ce: Burton Sweet, Cornerstone House, Midland Way, Thornbury Bristol BS35 2BS
4 MUSCUOSKEETA Are you experiencing any other problems with the muscles or joints of your hands/arms? Pain Swelling Stiffness Weakness If yes, give details: Do you have any diffi culty with fi ne movement of your fi ngers? If yes, is it continuous episodic Do any of these symptoms (blanching, tingling or numbness) affect your work or leisure activities? MEDICA EXAMINATION Opinion of atmospheric temperature: hot/warm/cool/cold wet/dry weather Appearance of hands te any signs of vascular disease, deformity, scars, calluses or muscle wasting Describe any abnormality of neck or upper limbs CICUATION, PUSE, BOOD PESSUE BP ying Sitting adial pulse Ulnar pulse rate present absent present absent Opus Health td. Company egistration.: egistered Offi ce: Burton Sweet, Cornerstone House, Midland Way, Thornbury Bristol BS35 2BS
5 NEVOUS SYSTEM ight Touch rmal Abnormal rmal Abnormal Pin Prick Manual Dexterity Neurological defect can be recorded on above diagram. Employee Declaration I consent to undertaking a Hand Arm Vibration Assessment Examination and a standard pro-forma being provided to management confi rming the results of this examination. Additional consent will be obtained should any result of this examination need to be discussed with Management. By ticking this box you are signing an agreement to the following statements: I declare that all the foregoing statements are complete and true to the best of my knowledge. Signature: Date: HAVS ESUTS Fit for work with exposure to hand-transmitted vibration: Comments: Date or Interval for Next HAVS review: efer to OHP - / Date referred Signature Name (print) Date seen Occupational Health Practitioner Date Opus Health td. Company egistration.: egistered Offi ce: Burton Sweet, Cornerstone House, Midland Way, Thornbury Bristol BS35 2BS
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