CORNELL UNIVERSITY BODY DISCOMFORT SURVEY
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To complete this worksheet type an 'x' into each
cell that indicates your answer to each question. If you have not experienced
a symptom you do not need to mark anything.
The data are automatically summarized. The data are also weighted for
the frequency of symptoms.
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Body discomfort
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FREQUENCY: During the last work week how often
did you experience ache, pain, discomfort:
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SEVERITY: If you experienced ache, pain,
discomfort, how uncomfortable was this?
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PRODUCTIVITY: If you experienced ache, pain,
discomfort, how much did this interfere with your ability to work?
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1-2 times last week
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3-4
times last week
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Once
every day
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Several
times every day
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Slightly
uncomfortable
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Moderately
uncomfortable
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Very
uncomfortable
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Slightly
interferred
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Substantially
interfered
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Eyestrain (right)
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Eyestrain (left)
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Headache
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Neck
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Shoulder (right)
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Shoulder (left)
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Upper back
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Lower back
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Upper arm (right)
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Upper arm (left)
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Forearm (right)
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Forearm (left)
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Wrist (right)
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Wrist (left)
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Hips/buttocks
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Thigh (right)
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Thigh (left)
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Knee (right)
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Knee (left)
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Lower leg (right)
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Lower leg (left)
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Ankle (right)
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Ankle (left)
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Foot (right)
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Foot (left)
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FREQUENCY
SUMMARY
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SEVERITY SUMMARY |
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PRODUCTIVITY SUMMARY |
Total 1-2 times/week
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Slightly
uncomfortable
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Slightly
interfered
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Total 3-4 times/week
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Moderately
uncomfortable
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Substantially
interfered
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Total every day
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Very
uncomfortable
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Total several times per day
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TOTAL WEIGHTED FREQUENCY SCORE
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TOTAL WEIGHTED SEVERITY SCORE
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TOTAL WEIGHTED PRODUCTIVITY
SCORE
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TOTAL MSD IMPACT SCORE
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© Professor Alan Hedge, Cornell University,
October 2010.
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