Health Surveillance Questionnaire

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.

Title Page

Conducted on
Prepared by
Employee Name
Occupation
- Bricklayer
- Plasterer
- Joiner
- Labourer
- Machine Driver
- Multi Skilled
- Other
Occupation?

Assessment

Have you ever been using hand-held vibrating tools, machines or hand-fed processes in your job, or if this is a review, since your last assessment?
Do you have any numbness or tingling of the fingers lasting more than 20 minutes after using vibrating equipment?
Do you have numbness or tingling of the fingers at any other time?
Do you wake at night with pain, tingling, or numbness in your hand or wrist?
Do one or more of your fingers go numb more than 20 minutes after using vibration equipment?
Have any of your fingers gone white* on cold exposure? <br>*White means a clear discoloration of the fingers with a sharp edge, followed by a red flush
do you have difficulty re-warming them when leaving the cold?
Do your fingers go white at any other time?
Have you noticed any change in your response to your tolerance of working outdoors in the cold?
Give Details
Are you experiencing any other problems in your hands or arms?
Give Details
Do you have difficulty picking up very small objects, eg screws or buttons or opening tight jars?
Has anything changed about your health since the last assessment ?
Give Details
Have you ever had a neck, arm or hand injury or operation?
Give Details
Have you ever had any serious diseases of joints, skin, nerves, heart or blood vessels?
Give Details
Are you on any long-term medication?
Give Details