Virtual Ergo Eval Form

Fill in the Virtual Ergonomic Evaluation Form and submit.

Name: *

Email: *

Company *

Reason for Evaluation *

Height: *

Weight: *

Please describe any medical issues that affect you while you are working *

Number of hours worked per week at this workstation *

How often do you travel for work? *

Do you use a laptop when traveling? *
Yes
No

When traveling, how many hours do you work at a desk/cubicle? *

When traveling, how many hours do you work in a hotel room or business center? *

Please upload your images here *

Upload additional images here *

Upload additional images here *

Please tell us any thing else we should know *

Are you interested in a sit-stand option? *

Please tell us about any discomfort you have when working:

Austin HealthWorks

Physical Therapy Ergonomics Wellness