SCREENING FORM

Name:

Age:

Gender:

Type of shop:

Contact no.

Address:

Work duration (in 24 hours):

History

Any recent musculoskeletal injury-Yes/No

Any neurological deficit-Yes/No

Any psychiatric disease-Yes/No

Risk factors could be contributing to musculoskeletal discomforts:

 Repetitive movements of upper extremity

 Static prolonged postures(standing/sitting)
 Exposure to vibration
 Carry heavy weight

Life employment duration (job seniority):