Work Environment and Symptoms
Daily work duties:
Work-related activities that aggravate your condition:
If you work at a computer, on average how many hours per day do you do so?
Do you experience
eyestrain? Y N If yes, please describe symptoms and frequency:
Please note your dominant hand: Right Left
Do you currently experience discomfort while working? Yes No
If yes, what are the symptoms? Please specify right or left where appropriate and be specific.
Approximate date symptoms first noticed: