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// CODE SNIPPET

Appendix F Medical Questionnaires, (Non-Mandatory)

OSHA 1910 General Industry > Z Toxic and Hazardous Substances > 1910.1051 1,3-Butadiene > F Medical Questionnaires, (Non-Mandatory)
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1,3-Butadiene (BD) Initial Health Questionnaire

DIRECTIONS:

You have been asked to answer the questions on this form because you work with BD (butadiene). These questions are about your work, medical history, and health concerns. Please do your best to answer all of the questions. If you need help, please tell the doctor or health care professional who reviews this form.

This form is a confidential medical record. Only information directly related to your health and safety on the job may be given to your employer. Personal health information will not be given to anyone without your consent.

Date: ______________

Name: ______________ ___________ ____             SSN ___/___/___
            Last                     First                MI

Job Title: __________________________

Company's Name: _____________________

Supervisor's Name: ________________           Supervisor's

                                                                             Phone No.: ( ) ____-_____

                                                                  Work History

  1. Please list all jobs you have had in the past, starting with the job you have now and moving back in time to your first job. (For more space, write on the back of this page.)

    Main Job Duty Years Company Name, City, State Chemicals
    1.
    2.
    3.
    4.
    5.
    6.
    7.
    8.
  2. Please describe what you do during a typical work day. Be sure to tell about you work with BD.

    ________________________________________________________________

    ________________________________________________________________

    ________________________________________________________________
  3. Please check any of these chemicals that you work with now or have worked with in the past:

    benzene ____
    glues ____
    toluene ____
    inks, dyes ____
    other solvents, grease cutters ____
    insecticides (like DDT, lindane, etc.) ____
    paints, varnishes, thinners, strippers ____
    dusts ____
    carbon tetrachloride ("carbon tet") ____
    arsine ____
    carbon disulfide ____
    lead ____
    cement ____
    petroleum products ____
    nitrites ____
  4. Please check the protective clothing or equipment you use at the job you have now:

    gloves ____
    coveralls ____
    respirator ____
    dust mask ____
    safety glasses, goggles ____

Please circle your answer of yes or no.
  1. Does your protective clothing or equipment fit you properly?
               yes            no
  2. Have you ever made changes in your protective clothing or equipment to make it fit better?
               yes            no
  3. Have you been exposed to BD when you were not wearing protective clothing or equipment?
               yes            no
  4. Where do you eat, drink and/or smoke when you are at work?
    (Please check all that apply.)

    Cafeteria/restaurant/snack bar ____
    Break room/employee lounge ____
    Smoking lounge ____
    At my work station ____
Please circle your answer.
  1. Have you been exposed to radiation (like x-rays or nuclear material) at the job you have now or at past jobs?

               yes            no
  2. Do you have any hobbies that expose you to dusts or chemicals (including paints, glues, etc.)?

               yes            no
  3. Do you have any second or side jobs?

               yes            no

    If yes, what are your duties there? _________________________

    _____________________________________________________________

    _____________________________________________________________

    _____________________________________________________________
  4. Were you in the military?

               yes            no

    If yes, what did you do in the military? ____________________

    _____________________________________________________________

    _____________________________________________________________

    _____________________________________________________________


                                                  Family Health History

  1. In the FAMILY MEMBER column, across from the disease name, write which family member, if any, had the disease.

    DISEASE FAMILY MEMBER
    Cancer
    Lymphoma
    Sickle Cell Disease or Trait
    Immune Disease
    Leukemia
    Anemia
  2. Please fill in the following information about family health:

    RELATIVE ALIVE? AGE AT DEATH? CAUSE OF DEATH?
    Father
    Mother
    Brother/Sister
    Brother/Sister
    Brother/Sister


                                       PERSONAL HEALTH HISTORY

Birth Date ___/___/___   Age ___   Sex ___   Height ___   Weight ___

Please circle your answer.

  1. Do you smoke any tobacco products?

               yes            no
  2. Have you ever had any kind of surgery or operation?

               yes            no

    If yes, what type of surgery: __________________________________

    ________________________________________________________________

    ________________________________________________________________
  3. Have you ever been in the hospital for any other reasons?

               yes            no

    If yes, please describe the reason: ____________________________

    ________________________________________________________________

    ________________________________________________________________
  4. Do you have any on-going or current medical problems or conditions?

               yes            no

    If yes, please describe: _______________________________________

    ________________________________________________________________

    ________________________________________________________________
  5. Do you now have or have you ever had any of the following?

    Please check all that apply to you.

    unexplained fever ____
    anemia ("low blood") ____
    HIV/AIDS ____
    weakness ____
    sickle cell ____
    miscarriage ____
    skin rash ____
    bloody stools ____
    leukemia/lymphoma ____
    neck mass/swelling ____
    wheezing ____
    yellowing of skin ____
    bruising easily ____
    lupus ____
    weight loss ____
    kidney problems ____
    enlarged lymph nodes ____
    liver disease ____
    cancer ____
    infertility ____
    drinking problems ____
    thyroid problems ____
    night sweats ____
    chest pain ____
    still birth ____
    eye redness ____
    lumps you can feel ____
    child with birth defect ____
    autoimmune disease ____
    overly tired ____
    lung problems ____
    rheumatoid arthritis ____
    mononucleosis("mono") ____
    nagging cough ____
Please circle your answer.
  1. Do you have any symptoms or health problems that you think may be related to your work with BD?

               yes            no

    If yes, please describe: _______________________________________

    ________________________________________________________________
  2. Have any of your co-workers had similar symptoms or problems?

               yes            no            don't know

    If yes, please describe: _______________________________________

    ________________________________________________________________
  3. Do you notice any irritation of your eyes, nose, throat, lungs, or skin when working with BD?

               yes            no
  4. Do you notice any blurred vision, coughing, drowsiness, nausea, or headache when working with BD?

               yes            no
  5. Do you take any medications (including birth control or over-the-counter)?

               yes            no

    If yes, please list: ___________________________________________

    ________________________________________________________________
  6. Are you allergic to any medication, food, or chemicals?

               yes            no

    If yes, please list: ___________________________________________

    ________________________________________________________________
  7. Do you have any health conditions not covered by this questionnaire that you think are affected by your work with BD?

               yes            no

    If yes, please explain: ________________________________________

    ________________________________________________________________
  8. Did you understand all the questions?

               yes            no


_________________________
         Signature

                                  1,3-Butadiene (BD) Update Health Questionnaire

DIRECTIONS:

You have been asked to answer the questions on this form because you work with BD (butadiene). These questions ask about changes in your work, medical history, and health concerns since the last time you were evaluated. Please do your best to answer all of the questions. If you need help, please tell the doctor or health care professional who reviews this form.

This form is a confidential medical record. Only information directly related to your health and safety on the job may be given to your employer. Personal health information will not be given to anyone without your consent.

Date: ______________

Name: ______________ ___________ ____              SSN ___/___/___
            Last                      First                MI

Job Title: __________________________

Company's Name: _____________________

Supervisor's Name: ________________          Supervisor's
                                                                           Phone No.: ( ) ____-_____

                                        Present Work History

  1. Please describe any NEW duties that you have at your job: ______

    ________________________________________________________________

    ________________________________________________________________

    ________________________________________________________________

    ________________________________________________________________
  2. Please list any additional job titles you have:

    ____________________________               _________________________

    ____________________________               _________________________

    ____________________________               _________________________
Please circle your answer.
  1. Are you exposed to any other chemicals in your work since the last time you were evaluated for exposure to BD?

               yes            no

    If yes, please list what they are: _____________________________

    ________________________________________________________________
  2. Does your personal protective equipment and clothing fit you properly?

               yes            no
  3. Have you made changes in this equipment or clothing to make it fit better?

               yes            no
  4. Have you been exposed to BD when you were not wearing protective equipment or clothing?

               yes            no
  5. Are you exposed to any NEW chemicals at home or while working on hobbies?

               yes            no

    If yes, please list what they are: _____________________________

    ________________________________________________________________
  6. Since your last BD health evaluation, have you started working any new second or side jobs?

               yes            no

    If yes, what are your duties there? ____________________________

    ________________________________________________________________

    ________________________________________________________________


                                                  Personal Health History

  1. What is your current weight?                  ___________ pounds
  2. Have you been diagnosed with any new medical conditions or illness since your last evaluation?

               yes            no

    If yes, please tell what they are: _____________________________

    ________________________________________________________________
  3. Since your last evaluation, have you been in the hospital for any illnesses, injuries, or surgery?

               yes            no

    If yes, please describe: _______________________________________

    ________________________________________________________________
  4. Do you have any of the following?

    Please place a check for all that apply to you.

    unexplained fever ____
    anemia ("low blood") ____
    HIV/AIDS ____
    weakness ____
    sickle cell ____
    miscarriage ____
    skin rash ____
    bloody rash ____
    leukemia/lymphoma ____
    neck mass/swelling ____
    wheezing ____
    chest pain ____
    bruising easily ____
    lupus ____
    weight loss ____
    kidney problems ____
    enlarged lymph nodes ____
    liver disease ____
    cancer ____
    infertility ____
    drinking problems ____
    thyroid problems ____
    night sweats ____
    still birth ____
    eye redness ____
    lumps you can feel ____
    child with birth defect ____
    autoimmune disease ____
    overly tired ____
    lung problems ____
    rheumatoid arthritis ____
    mononucleosis "mono" ____
    nagging cough ____
    yellowing of skin ____
Please circle your answer.
  1. Do you have any symptoms or health problems that you think may be related to your work with BD?

               yes            no

    If yes, please describe: _______________________________________

    ________________________________________________________________
  2. Have any of your co-workers had similar symptoms or problems?

               yes            no            don't know

    If yes, please describe: _______________________________________

    ________________________________________________________________
  3. Do you notice any irritation of your eyes, nose, throat, lungs, or skin when working with BD?

               yes            no
  4. Do you notice any blurred vision, coughing, drowsiness, nausea, or headache when working with BD?

               yes            no
  5. Have you been taking any NEW medications (including birth control or over-the-counter)?

               yes            no

    If yes, please list:

    __________________      _________________      ___________________

    __________________      _________________       ___________________
  6. Have you developed any NEW allergies to medications, foods, or chemicals?

               yes            no

    If yes, please list:

    __________________      _________________       ___________________

    __________________      _________________      ___________________
  7. Do you have any health conditions not covered by this questionnaire that you think are affected by your work with BD?

               yes            no

    If yes, please explain: ________________________________________

    ________________________________________________________________
  8. Did you understand all the questions?

               yes            no


_____________________
    Signature

[61 FR 56746, Nov. 4, 1996]

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