of the following tools do you use and how Q4 Approx. days per month Approx. hours per day (please tick all that apply and give details) Breaker/ / Cobra/ Hilti Wacker Plate Rail Saw/hand held or mounted disc cutter Impact Wrench / Bance /nut runner Hammer drill Angle / Rail grinder Strimmer / Chain saws Other (please specify) Do your fingers ever display any of the following symptoms? Q5 Yes No (please tick relevant box for each) Turning in cold weather? (whiteness means a clear discolouration of the fingers) If yes, do you have difficulty re-warming them when leaving the cold? Turning white at any other time? numb (loss of feeling) for more than 20 minutes after using vibrating tools? Tingling for more than 20 minutes using vibrating tools? Tingling at any other time? If you answered to any of the above: “yes” Do your symptoms affect your social/leisure activities? Do your symptoms affect your work activities? Have you ever been told that your symptoms are NOT caused by vibration (i.e. caused by another illness e.g. Raynaud’s disease or another disease)? Yes No Q6 Do you wake at night with pain, tingling or numbness in your hand or wrist? Do you have difficulties picking up very small objects (e.g. screws or buttons) or Q7 opening jars? Are you experiencing any other problems with the muscles or joints of the hands Q8 or arms? If please give details. “yes”, Q9 Have you ever had a serious neck, arm or hand injury or operation? If please give details. “yes”, Q10 Are you on any long term medication? If please give details. “yes”, Do you suffer from blanching, numbness and/or tingling in your nose, toes or Q11 feet? If please give details, including when you first noticed this “yes”, Q12 Have you ever been told that you: Suffer from Hand Arm Vibration Syndrome (HAVS) or Vibration Finger (VWF)? Should not use or should your use of Hand Held Vibrating Tools
Q4 of the following tools do you use and how (please tick all that apply and give details) Approx. days per month Approx. hours per day Breaker/ / Cobra/ Hilti Wacker Plate Rail Saw/hand held or mounted disc cutter Impact Wrench / Bance /nut runner Hammer drill Angle / Rail grinder Strimmer / Chain saws Other (please specify) Q5 Do your fingers ever display any of the following symptoms? (please tick relevant box for each) Yes No Turning in cold weather? (whiteness means a clear discolouration of the fingers) If yes, do you have difficulty re-warming them when leaving the cold? Turning white at any other time? numb (loss of feeling) for more than 20 minutes after using vibrating tools? Tingling for more than 20 minutes using vibrating tools? Tingling at any other time? If you answered “yes” to any of the above: Do your symptoms affect your social/leisure activities? Do your symptoms affect your work activities? Have you ever been told that your symptoms are NOT caused by vibration (i.e. caused by another illness e.g. Raynaud’s disease or another disease)? Yes No Q6 Do you wake at night with pain, tingling or numbness in your hand or wrist? Q7 Do you have difficulties picking up very small objects (e.g. screws or buttons) or opening jars? Q8 Are you experiencing any other problems with the muscles or joints of the hands or arms? If “yes”, please give details. Q9 Have you ever had a serious neck, arm or hand injury or operation? If “yes”, please give details. Q10 Are you on any long term medication? If “yes”, please give details. Q11 Do you suffer from blanching, numbness and/or tingling in your nose, toes or feet? If “yes”, please give details, including when you first noticed this Q12 Have you ever been told that you: Suffer from Hand Arm Vibration Syndrome (HAVS) or Vibration Finger (VWF)? Should not use or should your use of Hand Held Vibrating Tools
RB-IMS-501-Application-Pack-January-2018.docx