Healthcare Musculoskeletal Disorder Prevention Form

Healthcare Musculoskeletal Disorder Prevention Form

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Employment and Job Demands

Typical shift hours:    Average weekly hours:

Musculoskeletal Symptoms and History

Do you currently experience any of the following? (check all that apply)

Pain    Numbness    Tingling    Weakness    Stiffness    Swelling

Affected area(s):   Neck   Shoulder   Upper back   Lower back   Elbow   Wrist/Hand   Hip   Knee   Ankle/Foot  

Other affected area(s):

Date symptoms began:    Pain severity (0-10):

Risk Factor Assessment (observed / reported)

Repetitive motion    Forceful exertion    Awkward postures    Vibration exposure

Prolonged static postures    Heavy lifting/manual handling    Frequent bending/twisting    Inadequate rest breaks

Average lift weight (lbs):    Typical repetitions per minute:

Medical History

Preventive Measures and Recommendations

The clinician / safety officer recommends (check all that apply):

Workstation assessment/adjustment    Equipment/tool adjustment    Lift-assist device    Job rotation    Scheduled rest/stretch breaks

Task modification    Referral to physical therapy    Ergonomic training    Other (specify):

Recommended start date:    Follow-up review date:

Training and Acknowledgment

I acknowledge that I have received information regarding musculoskeletal disorder risks, early symptom reporting, and preventive measures. I understand that implementation of recommended controls is intended to reduce risk but cannot guarantee complete elimination of symptoms.

I acknowledge receipt of training and information.

Privacy, Consent and Authorization

By signing below I authorize the clinician and designated occupational health or safety representatives to conduct ergonomic evaluation, to document findings in my medical/occupational health record, and to communicate work-related restrictions or recommendations to my employer as necessary to implement preventive measures. I understand that health information will be handled in accordance with applicable privacy laws and workplace policies.

I understand that I may withdraw this authorization in writing at any time except to the extent that action has already been taken in reliance on this authorization. This authorization expires on: .

I certify that the information provided on this form is complete and accurate to the best of my knowledge. I agree to report new or changing symptoms promptly and to participate in recommended preventive measures or follow-up assessment.

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