Health Surveillance Questionnaire

June 13, 2011

Health surveillance questionnaire are designed to identify any members of a community, organization or institution who may be at risk of something in their environment. Such surveys help prevent such people from falling sick due to exposure to risks. In places of work, health surveillance records are kept by employers for purposes of ensuring that the health and safety of the employees is upheld.  Doctors also make recommendations about the work environment based on the data obtained from such survey forms. Each health surveillance questionnaire is designed to serve the specific needs in an industry. For example, people working in an environment where hand-held vibrating equipment is in common use may use the questionnaire below:




Employer Name ________________

Q1. How often to you use hand-held vibrating devices at work

a.for most part of the day

b.When something needs fixing. Specify the approximate hours per week _________

Q2. Have you ever experienced moments of numbness on your fingers?

If yes, is this after or during equipment use_______

Q3.  Have you ever experienced numbness or tingling in other parts of the body?

If yes, specify ____________

Q4. Do you have pre-existing diseases such as diseases of the joints, skin diseases, nerve diseases or heart diseases? ____________ (if yes, specify) ______________________

Q5.  Are you taking any medicines for your condition?  _______________

Q6. Do you experience whitening of hands especially in wet or cold weather?  ________

Q7. Is any part of your hand painful? __________

If so, is there a notable sequence when the pain registers, e.g. cold weather? (Specify) _________________________

Q8. Have you sought medical attention for the condition? _____________

Download Health Surveillance Questionnaire in Word Format

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