1. Handedness: _ Left Handed _ Right Handed
2. Typical input method percentage: Mouse _ % Letter Keys _ % Number Keys/Pad _ %
3. Do you use a laptop for work? Yes _ No _
a) If yes, how do you transport it? Single shoulder Strap _ Backpack _ Rollercase _
4. How many monitors do you use at your workstation? __
a) If more than one, do you turn your head to see each monitor? Yes __ No___
5. Do you sit under dim or flickering lights? Yes __ No __
6. Do you spend a lot of time looking down at papers on your desk? Yes ___ No ___
7. Corrective Lens: __ None ___ Single lens __ Bifocals ___Trifocals __ Progressives ___ Contacts
For bifocals, trifocals, or progressives, what part of the lens do you look through for
a) To view the monitor: ___Bottom _____Middle ___Top ____N/A
b) To read paper documents: ____Bottom _____Middle ___Top ____ N/A
c) When speaking to people: ____Bottom _____ Middle ___Top _____N/A
8. Have you had any pain or discomfort in the last year that you believe is related to your work? ____Yes _____ No
If yes, what location of your body? _____________________
9. When did you first notice this discomfort? (month)_____ (year)_______
10. Is it getting better, worse, or staying the same? ____Better ____Worse _____Same
11. Does the discomfort persist on weekends or days off? ______Yes _______No
A “yes” may point to a more advanced issue that warrants a medical referral.
Please check yes or no to following questions:
Upload Four (4) photos: ** See example Views/orientations below**
Have someone take photographs of you using a digital camera or phone camera approximately 2-3 feet away. Take a picture at 4 different angles while the client is sitting at the workstation/desk.
***Photos should be discreet and obstruct any private or company information.***
FULL BODY (LEFT) SIDE VIEW
FULL BODY (RIGHT) SIDE VIEW
FULL BODY FROM (REAR) VIEW
**(Members) only (Revitalize Program*) login granted after check-out.
