(for紙本繳交者)基本資料及健康問卷調查表

壹:

👉基本資料 Basic Information

*一、姓名 Name:

*二、性別 Gender:

男 Male
女 Female

*三、身分證字號(護照號碼) ARC ID number:

*四、(西元)出生日期 Date of Birth:

(yyyy/mm/dd)

*五、本校受僱日期 Date of Employment:

(yyyy/mm/dd)

貳:

👉作業經歷 Past Employment Experience:

*一、上一份工作 previous job:

若無，請不要留空，請填寫"無" Please do not leave anything blank. If something does not apply please put N/A

*(承上題)，起始日期 (To above the question)Started from:

(yyyy/mm)

若無，請不要留空，請填寫"無" Please do not leave anything blank. If something does not apply please put N/A

*(承上題)，截止日期(To above the question)Ended on:

(yyyy/mm)

若無，請不要留空，請填寫"無" Please do not leave anything blank. If something does not apply please put N/A

*二、目前從事 Current work as:

*(承上題)，起始日期 (To above the question)Started from:

(yyyy/mm)

若無，請不要留空，請填寫"無" Please do not leave anything blank. If something does not apply please put N/A

*(承上題)，截止日期(To above the question)Ended on:

(yyyy/mm)

若無，請不要留空，請填寫"無" Please do not leave anything blank. If something does not apply please put N/A

*三、過去 1 個月，平均每週工時為(In past 1 month,the average weekly working hours):

小時(hr)

*四、過去 6 個月，平均每週工時為(In past 6 month,the average weekly working hours):

小時(hr)

参:

👉既往病史 Personal Medical History

*您是否曾患有下列慢性疾病：（請在適當項目前打勾） Have you ever had underlying chronic diseases:(please mark in front of the appropriate items):

高血壓 Hypertension 糖尿病 Diabetes Mellitus 心臟病 Heart Disease 白內障 Cataract 中風 Stroke 癲癇 Seizure/Epilepsy 氣喘 Asthma 骨折 Fracture 貧血 Anemia 慢性氣管炎、肺氣腫 Chronic bronchitis、Emphysema
肺結核 Tuberculosis 腎臟病 Renal Disease 肝病 Liver Disease 中耳炎 Otitis Media 聽力障礙 Hearing Impairment 甲狀腺疾病 Thyroid disease 消化性潰瘍、胃炎 Peptic Ulcer、Gastritis 逆流性食道炎 Reflux Esophagitis 以上皆無 None

*(承上題)，其它疾病史(如:手術、癌症、其它慢性病) To above the question，Others History(Operation History, cancer, other chronic diseases):

若無，請不要留空，請填寫"無" Please do not leave anything blank. If something does not apply please put N/A

肆:

👉生活習慣 Life Style Habits

*一、請問您過去一個月內是否有吸菸？Have you ever been smoking in last 1 month？:

已經戒菸。Quitting smoking
從未吸菸。Never smoke.
偶爾吸(不是天天)Occasionally used(not everyday)。
幾乎、每天吸Almost every day used

*二、請問您最近六個月內是否有嚼食檳榔？Have you ever been using betel nuts in recent 6 months?:

已經戒食。Already quitted
從未嚼食檳榔。Never use.
偶爾嚼(不是天天) 。 Occasionally used(not everyday).
幾乎、每天嚼Almost every day used，

*三、請問您過去一個月內是否有喝酒？Have you ever been drinking in last 1 month?:

已經戒酒Already quitted
從未喝酒。Never drink.
偶爾喝(不是天天) 。Occasionally used(not everyday)
幾乎、每天喝Almost every day used

*工作日期間，平均每天睡眠時間為幾小時?(請問您於On working days, your average daily sleep hours):

1 2 3 4 5 6 7 8 9 10以上(More than 10 hours)

小時/hr

伍:

👉自覺症狀 Self-awareness Symptoms

*您最近三個月是否常有下列症狀：（請在適當項目前打勾） In the previous 3 months, have you frequently suffered from any of the symptoms listed below ? (please mark in front of t:

咳嗽 Cough 咳痰 Sputum 呼吸困難 Short of breath 胸痛 Chest pain 心悸 Palpitations 頭暈 Dizziness 頭痛 Headache 耳鳴 Tinnitus 倦怠 Fatigue 噁心 Nausea
腹痛 Abdominal pain 便秘 Constipation 腹瀉 Diarrhea 血便 Bloody or tarry stool 上背痛 Upper backache 下背痛 Lower backache 手腳麻痛 Numbness in extremities 關節疼痛 Arthralgia 排尿不適 Discomfort while urinating or dysuria 多尿、頻尿 Frequent urination or polyuria
手腳肌肉無力 Weakness of extremities 體重減輕 3 公斤以上 Body weight loss>3kg 以上皆無 None

*(承上題)其他症狀 (To above the question) Other:

若無，請不要留空，請填寫"無" Please do not leave anything blank. If something does not apply please put N/A

Ⅰ:

👉過勞(工作負荷)量表Overwork Survey:

依據「國立臺灣科技大學異常工作負荷促發疾病預防計畫」，為了保護教職員工安全健康，對於預防過勞所採取之相關措施，填寫"過勞量表"可檢測您的過勞情形。

According to the “NTUST Plan of preventing diseases from overwork”, to protect school staff healthy, fill up the “Overwork Survey” may help you understand your workload.

腦心血管疾病之促發，除個人因素(如原有疾病或生活習慣等)外，亦與工作負荷(長期壓力及工作疲勞累積)有關。

Excepting personal factor(diseases or habit), work load is an important factor of Cardiovascular diseases.

勞安所研發「過量表」做為職場工作者過勞問題的自我評估具，其包含「個人相關過勞」、「工作相關過勞」。
The survey includes personal-related overwork and work-related overwork.

(一)個人相關過勞分量表 Personal fatigue

1-6

*1.你常覺得疲勞嗎?Do you often feel tired?:

1、總是Always 2、常常Often 3、有時候Sometimes 4、不常Rarely 5、從未或幾乎從未Never

*2.常覺得身體上體力透支嗎?Do you often feel physically exhausted?:

1、總是Always 2、常常Often 3、有時候Sometimes 4、不常Rarely 5、從未或幾乎從未Never

*3.你常覺得情緒上心力交瘁嗎?Do you often feel emotionally exhausted?:

1、總是Always
2、常常Often
3、有時候Sometimes
4、不常Rarely
5、從未或幾乎從未Never

*4.你常會覺得，「我快要撐不下去了」嗎?Do you often feel “I cannot do it anymore”?:

1、總是Always
2、常常Often
3、有時候Sometimes
4、不常Rarely
5、從未或幾乎從未Never

*5.你常覺得精疲力竭嗎?Do you often feel exhausted?:

1、總是Always
2、常常Often
3、有時候Sometimes
4、不常Rarely
5、從未或幾乎從未Never

*6.你常常覺得虛弱，好像快要生病了嗎?Do you often feel weak and it seems that you are getting sick?:

1、總是Always
2、常常Often
3、有時候Sometimes
4、不常Rarely
5、從未或幾乎從未Never

Ⅱ:

(二)工作相關過勞分量表ork-related fatigue

1-7

*1.你的工作會令人情緒上心力交瘁嗎? Do you often feel mentally and physically exhausted of your job?::

1、總是Always
2、常常Often
3、有時候Sometimes
4、不常Rarely
5、從未或幾乎從未Never

*2.你的工作會讓你覺得快要累垮了嗎? Do you often feel fagged out by your job?::

1、總是Always
2、常常Often
3、有時候Sometimes
4、不常Rarely
5、從未或幾乎從未Never

*你的工作會讓你覺得挫折嗎? Do you often feel frustrated of your job?::

1、總是Always
2、常常Often
3、有時候Sometimes
4、不常Rarely
5、從未或幾乎從未Never

**4.工作一整天之後，你覺得精疲力竭嗎? Do you often fell wear out after a whole day of work?::

1、總是Always
2、常常Often
3、有時候Sometimes
4、不常Rarely
5、從未或幾乎從未Never

*5.上班之前只要想到又要工作一整天，你就覺得沒力嗎? Do you often feel lack of enthusiasm before punching into work?::

1、總是Always
2、常常Often
3、有時候Sometimes
4、不常Rarely
5、從未或幾乎從未Never

*6.上班時你會覺得每一刻都很難熬嗎? Do you often feel that your job is unbearable?::

1、總是Always
2、常常Often
3、有時候Sometimes
4、不常Rarely
5、從未或幾乎從未Never

**7.不工作的時候，你有足夠的精力陪朋友或家人嗎? Do you have enough energy to accompany your families/friends when you are off duty?:

1、總是Always
2、常常Often
3、有時Sometimes候
4、不常Rarely
5、從未或幾乎從未Never

平均月加班時數Average monthly overtime hoursAverage monthly overtime hours:

< 45小時(hr)
45~80小時(hr)
> 80小時(hr)

※:

▲:

👉肌肉骨骼症狀調查表 Nordic. Musculoskeletal Questionnaire

依據「國立臺灣科技大學人因性危害防止計畫」，為預防本校教職員工，因長期暴露在設計不理想的工作環境或重複性作業或不良的作業姿勢或者工作時間管理不當下，得及早採取相關預防措施。

According to the ”NTUST Plan of Human Factor hazard prevention”, to prevent school staffs from being exposed under unsatisfactory working environment or repetitive tasks or bad working posture or improper work time management, the school needs to figure out related precaution.

填寫肌肉骨骼症狀調查表，俾瞭解個別教職員工之肌肉骨骼或關節活動生理狀況，並及早針對其身體的疲勞、酸痛等不適症狀，採取相關預防措施，以防止發生因工作而引起的肌肉骨骼傷害或疾病等的人因性危害。

Fill up the Nordic. Musculoskeletal Questionnaire can make individual staff realize their physical condition, and take action to the discomfort symptoms earlier.

*您的慣用手?Handedness:

左手Left hand
右手Right hand

*您在過去的一年內，身體是否有長達二星期以上的疲勞、酸痛、發麻、刺痛等不舒服，或關節活動受到限制？In the past year, whether the body has more than two wee:

是,請接續填寫題目Yes(continue to fill out the form)
否,請直接至頁面最底部點選"送出"按鈕 No (submit the form.the"Send out" buttons appear at the bottom.)

身體部位酸痛、不適或影響關節活動之情形持續多久時間？:

1個月(1month)
3個月(3 months)
6個月(6 months)
1年(1 year)
3年(3 years)
3年以上(more than 3 years)

症狀調查-疼痛部位症狀(可參考圖示填寫)Investigation of musculoskeletal symptoms(Answer to Refer to the picture below.):