STANDARDIZED NORDIC MUSCULOSKELETAL QUESTIONNAIRE

Please answer the questions or tick (/) in the appropriate box.

PART A: BACKGROUND INFORMATION

1. Birth date (dd/mm/yy) :

2. Age : years

3. Gender : Male Female

4. Height : cm

5. Weight : kg

6. Marital Status : Single Married Others

7. Year Working : Year

8. Working hour : Hours

9. Part-time job : Yes No

PART B: SYMPTOM

Trouble with the Locomotive Organs

To be answered only by those who have had trouble.

Have you at What is the total length of
any time time that you have had
Have you
during the trouble during the last 12
Have you at any time during been seen
12 months months?
Have you at Have you by a doctor
the last 12 months had trouble been
in: any time ever hurt your because of
prevented

More than 30
during the body part in trouble

8-30 days

Everyday
from doing

1-7 days
last 7 days? an accident? during the

days
your normal
last 12
work
months?
because of
the trouble?
Neck YES NO YES NO YES NO YES NO YES NO
Shoulders YES NO YES NO YES NO YES NO YES NO
Elbow YES NO YES NO YES NO YES NO YES NO
Wrists/
YES NO YES NO YES NO YES NO YES NO
Hands
Hips/ Thighs YES NO YES NO YES NO YES NO YES NO
Upper Back YES NO YES NO YES NO YES NO YES NO
Low Back YES NO YES NO YES NO YES NO YES NO
Knees YES NO YES NO YES NO YES NO YES NO
Ankles/ Feet YES NO YES NO YES NO YES NO YES NO