// CODE SNIPPET
Appendix 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
Family Health History
PERSONAL HEALTH HISTORY
Birth Date ___/___/___ Age ___ Sex ___ Height ___ Weight ___
Please circle your answer.
_________________________
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
Personal Health History
_____________________
Signature
[61 FR 56746, Nov. 4, 1996]
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
- 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. - Please describe what you do during a typical work day. Be sure to
tell about you work with BD.
________________________________________________________________
________________________________________________________________
________________________________________________________________ -
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 ____ - Please check the protective clothing or equipment you use at the
job you have now:
gloves ____ coveralls ____ respirator ____ dust mask ____ safety glasses, goggles ____
- Does your protective clothing or equipment fit you properly?
yes no - Have you ever made changes in your protective clothing or
equipment to make it fit better?
yes no - Have you been exposed to BD when you were not wearing protective
clothing or equipment?
yes no - 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 ____
- Have you been exposed to radiation (like x-rays or nuclear
material) at the job you have now or at past jobs?
yes no - Do you have any hobbies that expose you to dusts or chemicals
(including paints, glues, etc.)?
yes no - Do you have any second or side jobs?
yes no
If yes, what are your duties there? _________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________ - Were you in the military?
yes no
If yes, what did you do in the military? ____________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Family Health History
- 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 -
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.
- Do you smoke any tobacco products?
yes no - Have you ever had any kind of surgery or operation?
yes no
If yes, what type of surgery: __________________________________
________________________________________________________________
________________________________________________________________ - Have you ever been in the hospital for any other reasons?
yes no
If yes, please describe the reason: ____________________________
________________________________________________________________
________________________________________________________________ - Do you have any on-going or current medical problems or
conditions?
yes no
If yes, please describe: _______________________________________
________________________________________________________________
________________________________________________________________ - 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 ____
- 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: _______________________________________
________________________________________________________________ - Have any of your co-workers had similar symptoms or problems?
yes no don't know
If yes, please describe: _______________________________________
________________________________________________________________ - Do you notice any irritation of your eyes, nose, throat, lungs,
or skin when working with BD?
yes no - Do you notice any blurred vision, coughing, drowsiness, nausea,
or headache when working with BD?
yes no - Do you take any medications (including birth control or
over-the-counter)?
yes no
If yes, please list: ___________________________________________
________________________________________________________________ - Are you allergic to any medication, food, or chemicals?
yes no
If yes, please list: ___________________________________________
________________________________________________________________ - 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: ________________________________________
________________________________________________________________ - 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
- Please describe any NEW duties that you have at your job: ______
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________ - Please list any additional job titles you have:
____________________________ _________________________
____________________________ _________________________
____________________________ _________________________
- 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: _____________________________
________________________________________________________________ - Does your personal protective equipment and clothing fit you
properly?
yes no - Have you made changes in this equipment or clothing to make it
fit better?
yes no - Have you been exposed to BD when you were not wearing protective
equipment or clothing?
yes no - Are you exposed to any NEW chemicals at home or while working on
hobbies?
yes no
If yes, please list what they are: _____________________________
________________________________________________________________ - 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
- What is your current weight? ___________ pounds
- Have you been diagnosed with any new medical conditions or
illness since your last evaluation?
yes no
If yes, please tell what they are: _____________________________
________________________________________________________________ - Since your last evaluation, have you been in the hospital for any
illnesses, injuries, or surgery?
yes no
If yes, please describe: _______________________________________
________________________________________________________________ - 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 ____
- 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: _______________________________________
________________________________________________________________ - Have any of your co-workers had similar symptoms or problems?
yes no don't know
If yes, please describe: _______________________________________
________________________________________________________________ - Do you notice any irritation of your eyes, nose, throat, lungs,
or skin when working with BD?
yes no - Do you notice any blurred vision, coughing, drowsiness, nausea,
or headache when working with BD?
yes no - Have you been taking any NEW medications (including birth control
or over-the-counter)?
yes no
If yes, please list:
__________________ _________________ ___________________
__________________ _________________ ___________________ - Have you developed any NEW allergies to medications, foods, or
chemicals?
yes no
If yes, please list:
__________________ _________________ ___________________
__________________ _________________ ___________________ - 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: ________________________________________
________________________________________________________________ - Did you understand all the questions?
yes no
_____________________
Signature
[61 FR 56746, Nov. 4, 1996]
Related Code Sections
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