Weekly Short Survey

* Participant #: (last 4 digits of office phone)

* Have you done anything outside of work that may have contributed to your discomfort?

Yes

No

If Yes, explain

During this work week how often did you experience discomfort?

	Never	1-2 times per/wk.	3-4 times per/wk.	Once everyday	Several times everyday
Eyes

Neck

Shoulder (Right)

Shoulder (Left)

Upper Back

Upper Arm (Right)

Upper Arm (Left)

Lower Back

Forearm (Right)

Forearm (Left)

	Never	1-2 times per/wk.	3-4 times per/wk.	Once everyday	Several times everyday
Wrist (Right)

Wrist (Left)

Hip/Buttocks (Right)

Hip/Buttocks (Left)

Thigh (Right)

Thigh (Left)

Knee (Right)

Knee (Left)

Lower Leg/Ankle (Right)

Lower Leg/Ankle (Left)

* If you experienced aches, pains or discomfort, how uncomfortable were you? (Slightly Uncomfortable, Moderately or Very Uncomfortable)? (Please list which body part you are experiencing pain/discomfort and then explain how uncomfortable.) Ex: Right Upper Arm - Very uncomfortable

* If you experienced aches, pains or discomfort, did this interfere with you ability to work?

* How much of your day do you spend sitting?

* What is the longest time you sit before getting up?