Body mapping tool
Have you at any time during the
last three months had trouble
(such as ache, pain, discomfort,
numbness, tingling, or pins and
needles) in your:
Have you had this
trouble during the last
seven days?
During the last three
months has this
trouble prevented you
carrying out normal
activities (e.g. job,
housework, hobbies)?
During the last three
months has this
trouble been caused
or made worse by
your job?
Neck 1 No Yes
1๎
2๎
2 No Yes
1๎
2๎
3 No Yes
1๎
2๎
4 No Yes
1๎
2๎
Caused
3๎
Made worse
Shoulders 5 No Yes
1๎
2๎
Right only
3๎
Left only
4๎
Both
6 No Yes
1๎
2๎
Right only
3๎
Left only
4๎
Both
7 No Yes
8 No Yes
1๎
2๎
Caused
3๎
Made worse
Elbows 9 No Yes
1๎
2๎
Right only
3๎
Left only
4๎
Both
10 No Yes
1๎
2๎
Right only
3๎
Left only
4๎
Both
11 No Yes 12 No Yes
1๎
2๎
Caused
3๎
Made worse
Wrists/
hands 13 No Yes
1๎
2๎
Right only
3๎
Left only
4๎
Both
14 No Yes
1๎
2๎
Right only
3๎
Left only
4๎
Both
15 No Yes
1๎
2๎
Right only
3๎
Left only
4๎
Both
16 No Yes
1๎
2๎
Caused
3๎
Made worse
This section asks about musculoskeletal
disorders, such as aches or pains, you
may have had recently. Please use the
tick boxes - โก - to answer each of the four
questions for each part of the body shown
in the picture on the right.
The picture shows how the body has been
divided. The areas of the body are not
sharply defined and some parts overlap.
You should decide for yourself which part
(if any) is or has been affected.
Please make sure you put one tick only for
each question. For example, you could
answer โYesโ for the right elbow, or the left
elbow, or both elbows.
1๎
2๎
Right only
3๎
Left only
4๎
Both
1๎
2๎
Right only
3๎
Left only
4๎
Both
