Body Discomfort Survey
The Body Discomfort Survey is a useful tool which assists a DSE Assessor in determining the areas of the
body causing discomfort or pain and how much this is affecting their ability to work.
Name:
Date:
Position:
Email:
Work Address:
Phone Number:
During the last working
week, how often did you
experience any aches, pains
or discomfort in?
1-2
times
last
week
Neck
Left Shoulder
Right Shoulder
Upper Back
Left Upper Arm
Right Upper Arm
Lower Back
Left Forearm
Right Forearm
Left Wrist
Right Wrist
Hip/Buttocks
Left Thigh
Right Thigh
Left Knee
Right Knee
Left Lower Leg
Right Lower Leg
Eyes
3-4
times
last
week
Once
every
day
Several
times
every
day
During the last working week, how
often did you experience any aches,
pains or discomfort, how uncomfortable
was this?
Slightly
uncomfortable
Moderately
uncomfortable
Very
uncomfortable
During the last working week,
how often did you experience
any aches, pains or
discomfort, did this interfere
with your ability to work?
Not
at
all
Slightly
interfered
Substantially
interfered