IBR QUESTIONNAIRE / ASSESSMENT

A QUESTIONNAIRE WAS MADE IN LANGUAGE BEST UNDERSTOOD BY THE PATIENT

A. TO FIND THE CURRENT (PRESENT) COMPLAINTS OF THE PATIENT:

1) WHAT IS TROUBLING YOU AT PRESENT?

2) HOW DID THE PROBLEM START?

3) WHEN DID IT START?

4) WHAT DID YOU DO TO REDUCE IT?

5) WHAT WERE THE SYMPTOMS?

6) WHERE WERE THE SYMPTOMS?

7) HOW DID THE SYMPTOMS INCREASE?

8) WHEN DID THEY INCREASE?

9) WERE YOU ABLE TO CONTINUE WITH YOUR WORK?

10) WHAT ACTIVITIES DID YOU STOP PERFORMING?

11) WHEN DID YOU CONSULT A DOCTOR?

12) WHY DID YOU COME TO MGM?

13) WHAT INVESTIGATIONS WERE DONE?

14) WERE YOU ON MEDICATIONS?

15) WHAT WAS DONE TO TREAT THE PROBLEM?

16) WHEN WAS THE TREATMENT DONE?

17) WAS THERE REDUCTION OF SYMPTOM AFTER TREATMENT?

18) WHAT ACTIVITIES CAN YOU DO AT PRESENT?

19) SINCE WHEN DID YOU REGAIN ACTIVITY?

20) SINCE WHEN ARE YOU ON PHYSIOTHERAPY TREATMENT?

21) DO YOU HAVE ANY OTHER COMPLAINTS?

B. TO FIND THE ASSOCIATED COMPLAINTS:

1) DO YOU HAVE ANY PAIN?

2) WHERE IS THE PAIN?

3) WHAT IS THE TYPE/INTENSITY/DURATION OF PAIN?

4) AGGRAVATING FACTORS?

5) RELIEVING FACTORS?

6) IS THERE ANY DIURNAL VARIATION?

7) DO YOU HAVE ANY SWELLING?

8) DO YOU HAVE PAIN ANYWHERE ELSE ON THE BODY?

C. TO FIND THE PAST HISTORY/FAMILY HISTORY:

1) HAVE YOU HAD ANY PREVIOUS SURGERY?

2) DOES ANYONE IN YOUR FAMILY HAVE SIMILAR CONDITION?

D. TO FIND THE PERSONAL HISTORY:

1) HOW IS YOUR SLEEP?

2) DO YOU FEEL HUNGRY?

3) DIET?

4) ADDICTIONS?

5) BOWEL/BLADDER?

IBR QUESTIONNAIRE / ASSESSMENT

E. TO FIND OUT EFFECT OF WORK ON OTHER SYSTEMS:

1) BREATHING PROBLEMS? COUGH? ALLERGY? SKIN RASH?

2) DO YOU FEEL MORE TIRED?

3) VISION PROBLEM? HEARING PROBLEM?

4) CHEST PAIN? ABDOMINAL PROBLEMS?

5) CONSTIPATION? URINATION PROBLEM?

F. TO FIND FUNCTIONAL INDEPENDENCE:

1) WHAT ACTIVITIES ARE RESTRICTED DUE TO SURGERY?

2) WHICH ACTIVITES WERE YOU ABLE TO PERFORM BEFORE SURGERY?

3) WHICH ACTIVITIES WERE RESTRICTED DUE TO YOUR SYMPTOMS?

G. JOB DEMAND ANALYSIS:

1) WHAT TYPE OF WORK DO YOU DO?

2) WHAT IS THE DURATION OF YOUR WORK?

3) WHAT ACTIVITIES DO YOU PERFORM?

4) HOW FREQUENTLY DO YOU PERFORM THESE ACTIVITIES?

5) WHAT KIND OF ENVIRONMENT DO YOU WORK IN?

6) WHAT TYPE OF HAZARDS SURROUND YOU WHEN YOU WORK?

7) WHAT KIND OF STRAIN DO YOU FACE WHILE WORKING?

8) HOW ARE THE CONDITIONS AT WORK?

H. TASK ANALYSIS:

1) WHAT IS THE MAXIMUM WEIGHT YOU LIFT/PUSH/PULL?

2) WHAT IS THE MINIMUM WEIGHT YOU LIFT/PUSH/PULL?

3) HOW MANY TIMES A DAY YOU PERFORM THESE ACTIVITIES?

4) HOW FAR DO YOU CARRY THE WEIGHT?

5) HOW MUCH FORCE DO YOU GENERATE WHILE PERFORMING VARIOUS ACTIVITIES?

6) HOW MANY TIMES DO YOU REPEAT THE SAME ACTIVITY?

7) FOR HOW LONG DO YOU DO A PARTICULAR ACTIVITY?

8) HOW FAR DO YOU REACH TO PERFORM THE ACTIVITIES?

9) FOR HOW LONG DO YOU GENERATE FORCE?

I. ERGONOMIC EVALUATION:

1) HOW MANY REST PAUSES DO YOU TAKE?

2) DO YOU USE BACK SUPPORT WHILE SITTING?

3) WHAT DO YOU SIT ON?

4) WHAT IS THE HEIGHT AT WHICH YOU SIT?

5) IS THERE ANY FOREARM SUPPORT WHILE SITTING?

6) WHAT IS THE HEIGHT AT WHICH REQUIRED EQUIPMENTS ARE PLACED?

J. ENVIRONMENTAL FACTORS ASSOCIATED WITH THE JOB:

1) HOW FAR WAS THE WORKPLACE FROM HOME?

2) HOW DO YOU TRAVEL?

3) DO YOU HAVE TO CLIMB STAIRS REGULARLY?

4) WHAT IS THE TYPE OF FLOORING/TOILET?

5) HOW FAR IS THE WORK STATION?

6) HOW IS THE VENTILATION & LIGHT AT YOUR PLACE?

IBR QUESTIONNAIRE / ASSESSMENT

7) IS SURROUNDING AREA CLEAN?

K. TO FIND OUT FACTORS OF NON-COMPLIANCE:

1) NO OF FAMILY MEMBERS?

2) NO IF EARNING MEMBERS?

3) IS YOUR FAMILY SUPPORTIVE?

4) ARE YOU AWARE ABOUT THE IMPORTANCE OF PHYSIOTHERAPY?

5) CAN YOU FIND TIME FOR PHYSIOTHERAPY TREATMENT?

6) HOW MANY HELP DO YOU GET AT WORK?

7) CAN YOU TAKE A LONG LEAVE OF ABSENCE?

L. TO FIND THE PSYCHOLOGICAL STATUS:

1) ARE YOU HAPPY?

2) DO YOU FEEL UPSET BECAUSE OF CONDITION?

3) DO YOU FEEL STRESSED OR ANXIOUS?

4) WAS THERE A RECENT EMOTIONAL EPISODE AT YOUR FAMILY?

5) ARE YOU WORRIED ABOUT YOUR JOB?

ASSESSMENT

I. JOB TITLE: (ACTUAL TITLE OF JOB)

II. JOB DESCRIPTION: (VERBAL OR WRITTEN DESCRIPTION OF FUNCTION)

III. VOCATIONAL PREPARATION: UNSKILLED / SEMI-SKILLED / SKILLED

IV. JOB DEMAND ANALYSIS (PHYSICAL DEMAND LEVEL):

S-Sedentary Work – Exerting up to 10 pounds of force occasionally (Occasionally: activity or

condition exists up to 1/3 of the time) and/or a negligible amount of force frequently

(Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull,

or otherwise move objects, including the human body. Sedentary work involves sitting most

of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary

if walking and standing are required only occasionally and all other sedentary

criteria are met.

LEVEL TRAINING TIME

1 SHORT DEMONSTRATION ONLY

2 ANYTHING BEYOND SHORT DEMONSTRATION UPTO AND INCLUDING 30 DAYS

3 OVER 30 DAYS UPTO AND INCLUDING 3 MONTHS

4 OVER 3 MONTHS UPTO AND INCLUDING 6 MONTHS

5 OVER 6 MONTHS UPTO AND INCLUDING 1 YEAR

6 OVER 1 YEAR UPTO AND INCLUDING 2 YEARS

7 OVER 2 YEARS UPTO AND INCLUDING 4 YEARS

8 OVER 4 YEARS UPTO AND INCLUDING 10 YEARS

9 OVER 10 YEARS

SVP SKILL LEVEL

UNSKILLED SVP = 1 & 2

SEMI- SKILLED SVP = 3 - 6

UNSKILLED SVP = 7 - 9

IBR QUESTIONNAIRE / ASSESSMENT

L-Light Work - Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of

force frequently, and/or a negligible amount of force constantly (Constantly: activity or

condition exists 2/3 or more of the time) to move objects. Physical demand requirements

are in excess of those for Sedentary Work. Even though the weight lifted may be only a

negligible amount, a job should be rated Light Work: (1) when it requires walking or standing

to a significant degree; or (2) when it requires sitting most of the time but

entails pushing and/or pulling of arm or leg controls; and/or (3) when the job requires

working at a production rate pace entailing the constant pushing and/or pulling of materials

even though the weight of those materials is negligible. NOTE: The constant stress and strain

of maintaining a production rate pace, especially in an industrial setting, can be and is

physically demanding of a worker even though the amount of force exerted is negligible.

M-Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds

of force frequently, and/or greater than negligible up to 10 pounds of force constantly to

move objects. Physical Demand requirements are in excess of those for Light Work.

H-Heavy Work - Exerting 50 to 100 pounds of force occasionally, and/or 25 to 50 pounds of

force frequently, and/or 10 to 20 pounds of force constantly to move objects. Physical

Demand requirements are in excess of those for Medium Work.

V-Very Heavy Work - Exerting in excess of 100 pounds of force occasionally, and/or in excess

of 50 pounds of force frequently, and/or in excess of 20 pounds of force constantly to move

objects. Physical Demand requirements are in excess of those for Heavy Work.

V. PHYSICAL DEMAND: (COMMENTS SECTION MAY INCLUDE EXAMPLES OF ACTIVITIES, UNUSUAL

ACTIVITY PERIODS, OUTSTANDING DEMANDS OR OTHER CONSIDERATION)

STRENGTH NOT AT ALL OCCASSIONALLY (<1 HR) FREQUENTLY (1-3 HRS) MAJOR DEMAND (>3 HRS) COMMENTS (MAX. /USUAL WT)

LIFTING

CARRYING

PUSHING

PULLING

FINE FINGER WORK

HANDLING

GRIPPING

REACH ABOVE SHOULDER

REACH BELOW SHOULDER

MOBILITY NOT AT ALL OCCASSIONALLY (<1 HR) FREQUENTLY (1-3 HRS) MAJOR DEMAND (>3 HRS) COMMENTS (MAX. /USUAL WT)

NECK MOTION

THROWING

SITTING

STANDING

WALKING

RUNNING

JUMPING

CLIMBING

BENDING / STOOP

KNEELING

CRAWLING

TWISTING

BALANCING

IBR QUESTIONNAIRE / ASSESSMENT

VI. TASK ANALYSIS: (DETAILED EXAMINATION OF JOB IN FORM OF FREQUENCY, DURATION, FORCES REQUIRED)

VII. WORK STATION ANALYSIS / ERGONOMIC EVALUATION: VIII. IDENTIFICATION OF RISK FACTORS: POSTURE/POSITION, FORCE, REPETITION, VIBRATION,

TEMPERATURE EXTREMES, STRESS/ATTITUDE, DIRECT PRESSURE, GENDER, AGE, PREVIOUS INJURIES, DISEASE, PHYSICAL STATURE, OBESITY

IX. OBJECTIVE ASSESSMENT

SENSORY / PERCEPTUAL NOT AT ALL OCCASSIONALLY (<1 HR) FREQUENTLY (1-3 HRS) MAJOR DEMAND (>3 HRS) COMMENTS (MAX. /USUAL WT)

HEARING

VISION (FAR/NEAR/ DEPTH/COLOUR)

PERCEPTION

FEELING

READING

WRITING

SPEECH

WORK ENVIRONMENT NOT AT ALL OCCASSIONALLY (<1 HR) FREQUENTLY (1-3 HRS) MAJOR DEMAND (>3 HRS) COMMENTS (MAX. /USUAL WT)

INSIDE WORK

OUTSIDE WORK

HOT/COLD

HUMID

DUST

VAPOR FUMES

NOISE

PROXIMITY TO OBJECTS

HAZARDOUS MACHINERY

SHARP TOOLS

RADIANT ENERGY

THERMAL ENERGY

SLIPPERY

CONGESTED WORKSIGHT

CHEMICALS

VIBRATIONS

JARRING

CONDITIONS OF WORK NOT AT ALL OCCASSIONALLY (<1 HR) FREQUENTLY (1-3 HRS) MAJOR DEMAND (>3 HRS) COMMENTS (MAX. /USUAL WT)

TRAVELLING

WORK ALONE

INTERACT WITH PEOPLE

OPERATE MACHINERY

IRREGULAR HOURS