Computer Ergonomics Risk Assessment

                            Visual Status                                                                   Muscle Skeletal Discomfort Profile                                                  

How many hours per day do operate a computer? ________ hrs.          Check (X) if you experience:

Time spent each day sitting? ____ hrs.                                                        ___ pain: (location)__________________________

Describe your computer activity? ________________________         ___ numbness: _____________________________

_________________________________________________            ___ tingling: ________________________________

Check (X) each which applies to you:                                                            ___ swelling: _______________________________

____ headaches: ___ front  ___ side ___ back   a.m./p.m.                        ___ tenderness: _____________________________

____ blurred vision: ___ near ___ far ___ both                                          ___ stiffness: _______________________________

____ double vision: ___ near ___ far ___ both                                           ___ soreness: _______________________________

___ focusing difficulty ___ near to far ___ far to near                             For each of those you indicate you experience; please indicate

                                 ___ from print to screen                                                the duration: less than 1 hour or between 4 - 8 hours or all day

___ eyes feel gritty: ___a.m. ___ p.m.                                                        or 2 - 3 times a week or every day

___ eyes burning: ___ a.m. ___ p.m.                                                           pain: ________________________________________

___ eyes feel itchy  ___a.m. ___ p.m.                                                         numbness: ____________________________________

___ redness in eyes  ___a.m. ___ p.m.                                                       tingling: ______________________________________

___ taking medication for: __________________________              swelling: ______________________________________

___ wear eyeglasses while operating a computer                                    tenderness: ___________________________________

___ wear contact lenses while operating a computer                              stiffness: _____________________________________

___ muscle stiffness in:                                                                               soreness: ____________________________________

___ neck  ___ shoulders  ___ back  ___ wrist  ___ other                     Please describe any sport or exercise program: ________

                RSI Preventive Measures                                                          

___ rest breaks    ___ keyboard tray  ___ lumbar  ___ chair               Please describe any hobbies: ______________________

___ document holder  ___ foot rest  ___ chair arm rests                    ____________________________________________

___ supports: ____ keyboard  ___ mouse                                            Please describe any previous accidents or injuries: