Appendix 3: Annual Screening Questionnaire For Health Surveillance

Appendix 3 Annual screening questionnaire for health surveillance
SCREENING QUESTIONNAIRE FOR WORKERS USING HAND-HELD

VIBRATING TOOLS, HAND-GUIDED VIBRATING MACHINES AND HAND-
FED VIBRATING MACHINES
Date:.........................................................................................................................
Employee name:........................................................................................................
Occupation:..............................................................................................................
Address:....................................................................................................................
Date of birth:............................................................................................................
National Insurance no:.............................................................................................
Employer name:........................................................................................................
Date of previous screening:.......................................................................................
Have you been using hand-held vibrating tools, machines or hand-fed Y/N
processes in your job, or if this is a review, since your last assessment?
(detail work history overleaf)
If NO or more than 2 years since last exposure please return the form - there is no
need to answer further questions.
If YES:
1 Do you have any numbness or tingling of the fingers lasting more than Y/N
20 minutes after using vibrating equipment?
2 Do you have numbness or tingling of the fingers at any other time? Y/N
3 Do you wake at night with pain, tingling, or numbness in your hand Y/N
or wrist?
4 Have any of your fingers gone white* on cold exposure? Y/N
*Whiteness means a clear discoloration of the fingers with a sharp edge, usually followed by a red
flush.
Blanching
110
5 Have you noticed any change in your response to your tolerance Y/N
of working outdoors in the cold?
6 Are you experiencing any other problems in your hands or arms? Y/N
7 Do you have difficulty picking up very small objects, eg screws Y/N

or buttons or opening tight jars?
8 Has anything changed about your health since the last assessment ? Y/N
I certify that all the answers given above are true to the best of my knowledge and
belief.
Signed: Date:
RETURN TO:
Hand-arm vibration syndrome (HAVS):
■ is a disorder which affects the blood vessels, nerves, muscles and joints of the
hand, wrist and arm;
■ can become severely disabling if ignored; and
■ its best known form is vibration white finger (VWF) which can be triggered
by cold or wet weather and can cause severe pain in the affected fingers.
Signs to look out for in hand-arm vibration syndrome:
■ tingling and numbness in the fingers;
■ in the cold and wet, fingers go white, then blue, then red and are painful;
■ you can't feel things with your fingers;
■ pain, tingling or numbness in your hands, wrists and arms;
■ loss of strength in hands.
OCCUPATIONAL HISTORY
Dates Job Title
……………………………………………………………………………………………...
……………………………………………………………………………………………...
……………………………………………………………………………………………...
……………………………………………………………………………………………...
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Appendix 3: Annual Screening Questionnaire For Health Surveillance

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Appendix 3 Annual screening questionnaire for health surveillance

SCREENING QUESTIONNAIRE FOR WORKERS USING HAND-HELD

National Insurance no:.............................................................................................

Date of previous screening:.......................................................................................

4 Have any of your fingers gone white* on cold exposure? Y/N

7 Do you have difficulty picking up very small objects, eg screws Y/N

Hand-arm vibration syndrome (HAVS):

■ can become severely disabling if ignored; and

Signs to look out for in hand-arm vibration syndrome:

■ tingling and numbness in the fingers;

■ you can't feel things with your fingers;

■ pain, tingling or numbness in your hands, wrists and arms;

■ loss of strength in hands.

Dates Job Title

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