HAVS Initial Questionnaire
HAVS Initial Questionnaire 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
*
Second Name
*
Date of Birth
*
Address - First Line
*
Address - Town
*
Address - County
*
Address - Post Code
*
Phone
*
Physical gender at birth
*
Male
Female
Company Name
*
Job Title/Position
*
General Practitioner Information
General Practitioner Address
*
Phone
*
Please complete for every role where you used vibrating tools.
Have you used vibrating tools in a previous role?
*
Yes
No
If yes, please provide, Employer name, Type of tools/machinery, Length of Employment?
*
Have any of your hobbies, secondary jobs or military reserve training ever involved any of the following?
Working near vibrating machines
*
Yes
No
If yes, please provide details (including date)
*
Working on buses, trucks or tractors
*
Yes
No
If yes, please provide details
*
Working with pneumatic drills, chainsaws, drills, etc
*
Yes
No
If yes, please provide details
*
Have you ever used hand held vibrating tools, machines or hand held processes in your job?
*
Yes
No
If yes, please provide details
*
Do you have tingling of the fingers at any other time?
*
Yes
No
If yes, please provide details
*
Do you wake at night with pain, tingling or numbness in your hand?
*
Yes
No
If yes, please provide details
*
Do one or more of your fingers go numb more than 20 minutes after using vibrating equipment?
*
Yes
No
If yes, please provide details
*
Do your fingers go white at any other time?
*
Yes
No
If yes, please provide details
*
Are you experiencing any other problem with muscles or joints of the hands or arms?
*
Yes
No
If yes, please provide details
*
Do you have difficulty picking up very small objects, e.g. screws or buttons or opening tight jars?
*
Yes
No
If yes, please provide details
*
Have you ever had neck, arm or hand injury or operation?
*
Yes
No
If yes, please provide details
*
Have you ever had any serious diseases of joints, skin, nerves, heart or blood vessels?
*
Yes
No
If yes, please provide details
*
Are you on any long term medication?
*
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
*
Submit
