CORNELL UNIVERSITY BODY DISCOMFORT SURVEY
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.
Body discomfort FREQUENCY: During the last work week how often did you experience ache, pain, discomfort: SEVERITY: If you experienced ache, pain, discomfort, how uncomfortable was this? PRODUCTIVITY: If you experienced ache, pain, discomfort, how much did this interfere with your ability to work?
1-2 times last week 3-4 times last week Once every day Several times every day Slightly uncomfortable Moderately uncomfortable Very uncomfortable Slightly interferred Substantially interfered
Eyestrain (right)
Eyestrain (left)
Headache
Neck
Shoulder (right)
Shoulder (left)
Upper back
Lower back
Upper arm (right)
Upper arm (left)
Forearm (right)
Forearm (left)
Wrist (right)
Wrist (left)
Hips/buttocks
Thigh (right)
Thigh (left)
Knee (right)
Knee (left)
Lower leg (right)
Lower leg (left)
Ankle (right)
Ankle (left)
Foot (right)
Foot (left)
     
FREQUENCY SUMMARY   SEVERITY SUMMARY   PRODUCTIVITY SUMMARY
Total 1-2 times/week   Slightly uncomfortable   Slightly interfered
Total 3-4 times/week   Moderately uncomfortable   Substantially interfered
Total every day   Very uncomfortable    
Total several times per day            
TOTAL WEIGHTED FREQUENCY SCORE   TOTAL WEIGHTED SEVERITY SCORE   TOTAL WEIGHTED PRODUCTIVITY SCORE
               
TOTAL MSD IMPACT SCORE          
               
             
© Professor Alan Hedge, Cornell University, October 2010.