Dental Ergonomics Risk Assessment Form
Dental Ergonomics Risk Assessment Form – Please complete this form to help us evaluate ergonomic risk factors in your dental work environment.
Full Name
First Name
Last Name
Role in Dental Practice
*
Please Select
Dentist
Dental Hygienist
Dental Assistant
Other Clinical Staff
Overall ergonomic risk level in your daily dental work
*
Low risk
1
2
3
4
High risk
5
1 is Low risk, 5 is High risk
How often do you experience any of the following symptoms during or after work?
*
Rows
Never
Rarely
Sometimes
Often
Always
Neck pain
1
2
3
4
5
Shoulder discomfort
6
7
8
9
10
Back pain
11
12
13
14
15
Wrist/hand discomfort
16
17
18
19
20
Eye strain
21
22
23
24
25
Workstation conditions assessment
*
Rows
Poor
Fair
Good
Excellent
Chair adjustability
26
27
28
29
Patient positioning
30
31
32
33
Instrument accessibility
34
35
36
37
Lighting quality
38
39
40
41
Typical duration of continuous dental procedures (in hours)
*
Less than 1 hour
1-2 hours
2-4 hours
More than 4 hours
Which ergonomic aids or equipment do you regularly use?
Magnification loupes
Adjustable chairs
Arm supports
Specialized lighting
None
What is your most common working posture?
*
Seated upright
Seated leaning forward
Standing
Alternating seated/standing
What support or ergonomic improvements would you find most helpful?
Additional comments or recommendations
Submit Assessment
Should be Empty: