HAVS Annual Questionnaire
HAVS Annual Assessment V2.0
Please complete the following questions. The information will remain confidential to the Occupational Health service and will not be divulged to any other person without your consent.
First Name
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Second Name
*
Date of Birth
*
Address - First Line
*
Address - Town
*
Address - County
*
Address - Post Code
*
Phone
*
Company Name
*
Job Title/Position
*
Vibrating tools history
Have you been using hand-held vibrating tools, machines or hand-fed processes in your job since your last vibration assessment?
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Yes
No
If yes, please provide details.
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Please complete this section
Have you noticed any new numbness or tingling of the fingers lasting more than 20 minutes after using vibrating equipment?
Yes
No
If yes, please provide details.
*
Have you been woken at night with pain, tingling or numbness in your hand or wrist?
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Yes
No
If yes, please provide details
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Have any of your fingers gone *white on cold exposure? *A clear discolouration of the fingers with a sharp edge usually followed by a red flush
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Yes
No
If yes, please provide details
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Have you noticed any change in your ability to working outdoors in the cold?
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Yes
No
If yes, please provide details
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Are you experiencing any other problems in your hands or arms?
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Yes
No
If yes, please provide details
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Have you noticed any increased difficulty in picking up small objects eg screws/buttons/coins or opening tight jars?
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Yes
No
If yes, please provide details
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Has anything changed about your health since your last assessment?
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Yes
No
If yes, please provide details
*
DECLARATION
I certify that the answers to the above questions are correct to the best of my knowledge. I understand that no medical details will be divulged without my permission to any person outside the Occupational Health Service, but an opinion about my fitness to work will be given to Management.
Enter your full name to confirm the above information
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Submit
