Appendix F Medical Questionnaires, (Non-Mandatory)

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.

5. Does your protective clothing or equipment fit you properly?
              yes            no
6. Have you ever made changes in your protective clothing or equipment to make it fit better?
              yes            no
7. Have you been exposed to BD when you were not wearing protective clothing or equipment?
              yes            no
8. 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.

9. Have you been exposed to radiation (like x-rays or nuclear material) at the job you have now or at past jobs?
   
              yes            no
10. Do you have any hobbies that expose you to dusts or chemicals (including paints, glues, etc.)?
    
               yes            no
11. Do you have any second or side jobs?
    
               yes            no
    
    If yes, what are your duties there? _________________________
    
    _____________________________________________________________
    
    _____________________________________________________________
    
    _____________________________________________________________
12. 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.

6. 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: _______________________________________
   
   ________________________________________________________________
7. Have any of your co-workers had similar symptoms or problems?
   
              yes            no            don't know
   
   If yes, please describe: _______________________________________
   
   ________________________________________________________________
8. Do you notice any irritation of your eyes, nose, throat, lungs, or skin when working with BD?
   
              yes            no
9. Do you notice any blurred vision, coughing, drowsiness, nausea, or headache when working with BD?
   
              yes            no
10. Do you take any medications (including birth control or over-the-counter)?
    
               yes            no
    
    If yes, please list: ___________________________________________
    
    ________________________________________________________________
11. Are you allergic to any medication, food, or chemicals?
    
               yes            no
    
    If yes, please list: ___________________________________________
    
    ________________________________________________________________
12. 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: ________________________________________
    
    ________________________________________________________________
13. 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.

3. 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: _____________________________
   
   ________________________________________________________________
4. Does your personal protective equipment and clothing fit you properly?
   
              yes            no
5. Have you made changes in this equipment or clothing to make it fit better?
   
              yes            no
6. Have you been exposed to BD when you were not wearing protective equipment or clothing?
   
              yes            no
7. Are you exposed to any NEW chemicals at home or while working on hobbies?
   
              yes            no
   
   If yes, please list what they are: _____________________________
   
   ________________________________________________________________
8. 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.

5. 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: _______________________________________
   
   ________________________________________________________________
6. Have any of your co-workers had similar symptoms or problems?
   
              yes            no            don't know
   
   If yes, please describe: _______________________________________
   
   ________________________________________________________________
7. Do you notice any irritation of your eyes, nose, throat, lungs, or skin when working with BD?
   
              yes            no
8. Do you notice any blurred vision, coughing, drowsiness, nausea, or headache when working with BD?
   
              yes            no
9. Have you been taking any NEW medications (including birth control or over-the-counter)?
   
              yes            no
   
   If yes, please list:
   
   __________________      _________________      ___________________
   
   __________________      _________________       ___________________
10. Have you developed any NEW allergies to medications, foods, or chemicals?
    
               yes            no
    
    If yes, please list:
    
    __________________      _________________       ___________________
    
    __________________      _________________      ___________________
11. 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: ________________________________________
    
    ________________________________________________________________
12. Did you understand all the questions?
    
               yes            no

_____________________
    Signature

[61 FR 56746, Nov. 4, 1996]