The high percentage of musculoskeletal symptoms (MSS) found in studies of general populations and various occupational groups underlines the need to distinguish between severely and mildly affected individuals. To investigate associations between MSS and quality of life, we examined the frequency of MSS on a five-point scale, health-related quality of life (SF-36) and sickness absence among 5654 workers in the aluminium industry. High frequencies of MSS from all body parts were related to lower scores on the SF-36 and increased sickness absence. This relationship was strongest for MSS from the lower back. Workers who reported low back MSS 'very often' had a mean role--physical score equivalent to that of the 15th percentile of the general population. These results show that workers who reported MSS often or very often were severely affected, and this scale can therefore be used to distinguish individuals at high risk for reduced health-related quality of life and sickness absence.