Please enable JavaScript in your browser to complete this form.姓名 Name (中英/ Chinese and english) *電話 Phone *地址 Address *Email *受傷日期 Date of injury * 你有照X-光嗎? Have you had an x-ray? *有 Yes無 No你有照磁力共振(MRI)嗎? Have you had any MRI? *有 Yes無 No工種 Trade *木工 Woodworker打樁工 Piling Operative地渠及喉管工 Drain and Pipe Layer泥水工 Cement Sand Mortar Worker地磚鋪砌工 Paving Block Layer金屬鋼鐵工 Metal-steel Worker建造貨運車輛駕駛員 Construction Vehicle Driver焊接工 Welder混凝土及灌漿工 Concrete and Grouting Worker窗框工 Window Frame Installer棚架工 Scaffolder升降機及自動梯技工電工 Electrician鋼筋屈紮工 Bar Bender and Fixer髹漆及裝飾工 Painter and Decorator其他 Others你在這公司工作了多久? How long have you been working at this company? *您從事同一類型的工作多久? How long have you been working in the same trade? *您對重返工作有什麼憂慮？What are your plans concerning returning to work? *在受傷之前日常的工作日中，您是否需要 坐 Sit *從不 Never偶爾 Occasionally (少於2.5hours)經常 Frequent (2.5-5hours)頻繁 Constant (>5hours)站 Stand *從不 Never偶爾 Occasionally (少於2.5hours)經常 Frequent (2.5-5hours)頻繁 Constant (>5hours)步行 *從不 Never偶爾 Occasionally (少於2.5hours)經常 Frequent (2.5-5hours)頻繁 Constant (>5hours)蹲下 Squat/Crouch *從不 Never偶爾 Occasionally (少於2.5hours)經常 Frequent (2.5-5hours)頻繁 Constant (>5hours)彎腰 Bend/Scoop *從不 Never偶爾 Occasionally (少於2.5hours)經常 Frequent (2.5-5hours)頻繁 Constant (>5hours)爬樓梯/梯子 Climb Stairs/Ladders *從不 Never偶爾 Occasionally (少於2.5hours)經常 Frequent (2.5-5hours)頻繁 Constant (>5hours)伸手觸及 Reach *從不 Never偶爾 Occasionally (少於2.5hours)經常 Frequent (2.5-5hours)頻繁 Constant (>5hours)爬行 Crawl *從不 Never偶爾 Occasionally (少於2.5hours)經常 Frequent (2.5-5hours)頻繁 Constant (>5hours)跪地 Kneel *從不 Never偶爾 Occasionally (少於2.5hours)經常 Frequent (2.5-5hours)頻繁 Constant (>5hours)特別姿勢 Awkward posture *從不 Never偶爾 Occasionally (少於2.5hours)經常 Frequent (2.5-5hours)頻繁 Constant (>5hours)平衡工作 Balance work *從不 Never偶爾 Occasionally (少於2.5hours)經常 Frequent (2.5-5hours)頻繁 Constant (>5hours)高空工作 Work above ground *從不 Never偶爾 Occasionally (少於2.5hours)經常 Frequent (2.5-5hours)頻繁 Constant (>5hours) 從地面抬起重物至腰 Lifting from Floor to Waist *從不 Never偶爾 Occasionally (1-15次 times)經常 Frequent (16-200 次 times)頻繁 Constant (>200 次 times)Single Line Text 從膝蓋抬起重物到腰 Lifting from Knee to Waist *從不 Never偶爾 Occasionally (1-15次 times)經常 Frequent (16-200 次 times)頻繁 Constant (>200次 times)Single Line Text (copy) 從腰抬起重物到肩膀 Lifting from Waist to Shoulder *從不 Never偶爾 Occasionally (1-15次 times)經常 Frequent (16-200 次 times)頻繁 Constant (>200次 times)Single Line Text (copy) (copy) 從腰抬起重物高於頭部 Lifting from Waist to Overhead *從不 Never偶爾 Occasionally (1-15次 times)經常 Frequent (16-200 次 times)頻繁 Constant (>200次 times)Single Line Text (copy) (copy) (copy)推 Push *從不 Never偶爾 Occasionally (1-15次 times)經常 Frequent (16-200 次 times)頻繁 Constant (>200次 times)Single Line Text (copy) (copy)拉 Pull *從不 Never偶爾 Occasionally (1-15次 times)經常 Frequent (16-200 次 times)頻繁 Constant (>200次 times)Submit