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過負荷評估表 Work/Body Load Assessment Form


姓名: 許o遠性別: 男性出生日期: 1978/06/12到職日: 2021/01/25職稱:


個人過去病史 Personal past medical history

*(經醫師確定診斷，可複選) Be diagnosis, the question allowed multiple answers

心臟循環系統疾病 Cardiovascular disease 腦中風 Cerebrovascular accident (CVA) or Stroke
血脂肪異常 Dyslipidaemia 睡眠相關呼吸疾病(如睡眠呼吸中止症) Sleep related breathing disorder
中樞神經系統疾病(如癲癇、脊椎疾病) Central nervous system diseases (e.g. epilepsy, spinal
diseases) 周邊神經系統疾病(如腕隧道症候群) Peripheral nervous system diseases (such as carpal
tunnel syndrome) 情感或心理疾病 Emotional or mental illness 眼睛疾病(不含可以矯正之近視或遠視) Ocular
diseases (excluding of myopia or hyperopia can be corrected) 聽力損失 Hearing loss
上肢或下肢疾病(如會導致關節僵硬、無力等症狀之疾病) Upper or lower extremity disease (e.g., cause joint
stiffness, weakness and other symptoms of the disease) 糖尿病 Diabetes 氣喘 Asthma
長期服藥 Long-term medication，藥物名稱 The name of the drug： 其他 Other 以上均無 None of above

*心臟循環系統疾病(可複選) Cardiovascular disease, the question allowed multiple answers

心絞痛 Angina 冠心病 Coronary Heart Disease 心肌梗塞 Myocardial infarction 接受心導管支架手術 Have
had cardiac catheterization and stent placement 曾接受冠狀動脈繞道手術 Have had coronary
artery bypass surgery 冠狀動脈疾病接受藥物治療 Coronary artery disease receiving medication
高血壓 Hypertension 心律不整 Arrhythmia 以上皆無 None of above 其他Other:：


家族史 Family disease history

*家族史 Family disease history 無 None一等親內的家屬(父母、祖父母、子女) 男性於55歲、女性於65歲前發生狹心症或心絞痛
Angina in first-degree relatives (defined as angina occurring before age 55
years in men and before age 65 years in women)家族中有中風病史 Family history of stroke
其他Other:：


生活習慣史 History of lifestyle

*抽菸 Smokes 無 No有 Yes已戒幾年 How many years have you quit smoking?

*每天幾包 If so, how many packs of cigarettes per day do you smoke?

*抽菸共幾年 How many years have you smoked?

*檳榔 Betel nut 無 No有 Yes已戒檳榔幾年 How many years have you quit betel nut?

*每天幾顆 If so, how many betel nuts per day do you eat?

*吃檳榔共幾年 If you have eaten betel nuts, how many years have you eaten?

*喝酒 Drinking 無 No有 Yes

*種類: If so, what kind of alcoholic beverages have you consumed

*頻率: If you drink, how often do you drink

*每次大約多少ml. If you drink, how many ml do you drink each time?

*用餐時間不正常 No regular meal time 否 No是 Yes

*外食頻率 Average frequency of eating out per day 無 No一餐 One meal a day兩餐 Two meals
a day三餐 Three meals a day

*自覺睡眠不足 Consciously lack of sleep 否 No是 Yes

*工作日睡眠平均幾小時 Average hours of sleep during workdays

*假日睡眠平均幾小時 Average hours of sleep during holidays

*運動習慣 Exercise habits 無 No有 Yes

*每週運動幾次 How many times do you exercise every week?

*每週運動幾分鐘 How many minutes do you exercise every week?

其他 Other


工作相關因素

*工作環境(可複選) Risk factors at worksite. The question allowed multiple answers.

噪音(分貝) Noise (dB) 異常溫度 Abnormal temperature (such as: ambient temperature
greater than 37 (℃), relative humidity greater than 40%) 通風不良 Poor ventilation
(for example, insufficient fresh air, unadjusted temperature and concentration
of harmful substances) 人因工程設計不良(如:座椅、震動、搬運等) Poor human engineering design (such
as seats, vibration, handling, etc.) 以上皆無 None of above.

異常溫度高溫約幾度 What is the maximum degree of temperature in your worksite?

異常溫度低溫約幾度 What is the minimum degree of temperature in your worksite?

*日常伴隨緊張之工作負荷(可複選) The question allowed multiple answers

經常負責會威脅自己或他人生命、財產的危險性工作 You’re often responsible for potentially dangerous or
harmful work that could be threat someone's life or property 有迴避危險責任的工作 Work
with responsibility to prevent danger 關乎人命、或可能左右他人一生重大判決的工作 You’re responsible
for making major judgments of relative someone’s life or his/her further life
experiences. 處理高危險物質的工作 Work with highly hazardous substances 可能造成社會龐大損失責任的工作
Your work may cause huge loss of society. 有過多或過分嚴苛的限時工作 There are too many or
too strict time-limited work 需在一定的期間內(如交期等)完成的困難工作 Difficult tasks that need to
be completed within a certain period (such as delivery time, etc.)
負責處理客戶重大衝突或複雜的勞資紛爭 Responsible for handling major customer conflicts or complex
labor disputes 無法獲得周遭理解或孤立無援狀況下的困難工作 Difficult work in an incomprehensible or
isolated situation 負責複雜困難的開發業務、或公司重建等工作 Responsible for complex and difficult
development business, or company reconstruction, etc. 以上皆無 None of above

*有無工作相關突發異常事件(如近期發生車禍、車子於行駛中發生重大故障等) Whether there are any unexpected
work-related incidents (such as recent car accidents, major breakdowns in the
car, etc.) 無 No有 請說明 Yes, please specify：

*工作環境中有無組織文化、職場正義問題(如職場人際衝突、部門內部溝通管道不足等?) Are there organizational culture and
workplace justice issues in the work environment (such as interpersonal
conflicts in the workplace, insufficient communication channels within the
department, etc.) 無 No有 請說明 Yes, please specify :

*對預定之工作排程或工作內容經常性變更或無法預估、常屬於事前的通知狀況等? Is the scheduled work schedule or work
content frequently changed or unpredictable, often due to prior notification
status, etc.? 無 No有 請說明 Yes, please specify :

經常性出差，其具有時差、無法休憩、休息或適當住宿、長距離自行開車或往返兩地而無法恢復疲勞狀況等? Go on a business trip usually,
and it is accompanied by jet lag, lack of enough time to rest, no proper
accommodation, Long distance driving……… 無 No有 請說明 Yes, please specify:


非工作相關因素 Non-work related factors

*家庭因素問題 Family related factors 無 No有 請說明 Yes,please specify :

經濟因素問題 Economic related factors 無 No有 請說明 Yes, please specify :