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- Identification
Plant Name
Date
Employee Name
S.S. #
Job Title
Birthdate:
Age:
Sex:
Height:
Weight:
- Medical History
- Have you ever been in the hospital as a patient?
Yes__ No__
If yes, what kind of problem were you having?
- Have you ever had any kind of operation?
Yes__ No__
If yes, what kind?
- Do you take any kind of medicine regularly?
Yes__ No__
If yes, what kind?
- Are you allergic to any drugs, foods, or chemicals?
Yes__ No__
If yes, what kind of allergy is it?
What causes the allergy?
- Have you ever been told that you have asthma, hayfever, or sinusitis?
Yes__ No__
- Have you ever been told that you have emphysema, bronchitis, or any
other respiratory problems?
Yes__ No__
- Have you ever been told you had hepatitis?
Yes__ No__
- Have you ever been told that you had cirrhosis?
Yes__ No__
- Have you ever been told that you had cancer?
Yes__ No__
- Have you ever had arthritis or joint pain?
Yes__ No__
- Have you ever been told that you had high blood pressure?
Yes__ No__
- Have you ever had a heart attack or heart trouble?
Yes__ No__
- B-1. Medical History Update
- Have you been in the hospital as a patient any time within the past
year?
Yes__ No__
If so, for what condition?
- Have you been under the care of a physician during the past year?
Yes__ No__
If so, for what condition?
- Is there any change in your breathing since last year?
Yes__ No__
Better?
Worse?
No change?
If change, do you know why?
- Is your general health different this year from last year?
Yes__ No__
If different, in what way?
- Have you in the past year or are you now taking any medication on a
regular basis?
Yes__ No__
Name Rx
Condition being treated
- Occupational History
- How long have you worked for your present employer?
- What jobs have you held with this employer? Include job title and
length of time in each job.
- In each of these jobs, how many hours a day were you exposed to
chemicals?
- What chemicals have you worked with most of the time?
- Have you ever noticed any type of skin rash you feel was related to
your work?
Yes__ No__
- Have you ever noticed that any kind of chemical makes you cough?
Yes__ No__
Wheeze?
Yes__ No__
Become short of breath or cause your chest to become tight?
Yes__ No__
- Are you exposed to any dust or chemicals at home?
Yes__ No__
If yes, explain:
- In other jobs, have you ever had exposure to:
Wood dust?
Yes__ No__
Nickel of chromium?
Yes__ No__
Silica (foundry, sand blasting)?
Yes__ No__
Arsenic or asbestos?
Yes__ No__
Organic solvents?
Yes__ No__
Urethane foams?
Yes__ No__
- C-1. Occupational History Update
- Are you working on the same job this year as you were last year?
Yes__ No__
If not, how has your job changed?
- What chemicals are you exposed to on your job?
- How many hours a day are you exposed to chemicals?
- Have you noticed any skin rash within the past year you feel was
related to your work?
Yes__ No__
If so, explain circumstances:
- Have you noticed that any chemical makes you cough, be short of
breath, or wheeze?
Yes__ No__
If so, can you identify it?
- Miscellaneous
- Do you smoke?
Yes__ No__
If so, how much and for how long?
Pipe
Cigars
Cigarettes
- Do you drink alcohol in any form?
Yes__ No__
If so, how much, how long, and how often?
- Do you wear glasses or contact lenses?
Yes__ No__
- Do you get any physical exercise other than that required to do your
job?
Yes__ No__
If so, explain:
- Do you have any hobbies or "side jobs" that require you to use
chemicals, such as furniture stripping, sand blasting, insulation or
manufacture of urethane foam, furniture, etc?
Yes__ No__
If so, please describe, giving type of business or hobby, chemicals
used and length of exposures.
- Symptoms Questionnaire
- Do you ever have any shortness of breath?
Yes__ No__
If yes, do you have to rest after climbing several flights of stairs?
Yes__ No__
If yes, if you walk on the level with people your own age, do you walk
slower than they do?
Yes__ No__
If yes, if you walk slower than a normal pace, do you have to limit the
distance that you walk?
Yes__ No__
If yes, do you have to stop and rest while bathing or dressing?
Yes__ No__
- Do you cough as much as three months out of the year?
Yes__ No__
If yes, have you had this cough for more than two years?
Yes__ No__
If yes, do you ever cough anything up from chest?
Yes__ No__
- Do you ever have a feeling of smothering, unable to take a deep
breath, or tightness in your chest?
Yes__ No__
If yes, do you notice that this on any particular day of the week?
Yes__ No__
If yes, what day or the week?
Yes__ No__
If yes, do you notice that this occurs at any particular place?
Yes__ No__
If yes, do you notice that this is worse after you have returned to
work after being off for several days?
Yes__ No__
- Have you ever noticed any wheezing in your chest?
Yes__ No__
If yes, is this only with colds or other infections?
Yes__ No__
Is this caused by exposure to any kind of dust or other material?
Yes__ No__
If yes, what kind?
- Have you noticed any burning, tearing, or redness of your eyes when
you are at work?
Yes__ No__
If so, explain circumstances:
- Have you noticed any sore or burning throat or itchy or burning nose
when you are at work?
Yes__ No__
If so, explain circumstances:
- Have you noticed any stuffiness or dryness of your nose?
Yes__ No__
- Do you ever have swelling of the eyelids or face?
Yes__ No__
- Have you ever been jaundiced?
Yes__ No__
If yes, was this accompanied by any pain?
Yes__ No__
- Have you ever had a tendency to bruise easily or bleed excessively?
Yes__ No__
- Do you have frequent headaches that are not relieved by aspirin or
tylenol?
Yes__ No__
If yes, do they occur at any particular time of the day or week?
Yes__ No__
If yes, when do they occur?
- Do you have frequent episodes of nervousness or irritability?
Yes__ No__
- Do you tend to have trouble concentrating or remembering?
Yes__ No__
- Do you ever feel dizzy, light-headed, excessively drowsy or like you
have been drugged?
Yes__ No__
- Does your vision ever become blurred?
Yes__ No__
- Do you have numbness or tingling of the hands or feet or other parts
of your body?
Yes__ No__
- Have you ever had chronic weakness or fatigue?
Yes__ No__
- Have you ever had any swelling of your feet or ankles to the point
where you could not wear your shoes?
Yes__ No__
- Are you bothered by heartburn or indigestion?
Yes__ No__
- Do you ever have itching, dryness, or peeling and scaling of the
hands?
Yes__ No__
- Do you ever have a burning sensation in the hands, or reddening of
the skin?
Yes__ No__
- Do you ever have cracking or bleeding of the skin on your hands?
Yes__ No__
- Are you under a physician's care?
Yes__ No__
If yes, for what are you being treated?
- Do you have any physical complaints today?
Yes__ No__
If yes, explain?
- Do you have other health conditions not covered by these questions?
Yes__ No__
If yes, explain:
Related Code Sections
Identification
Plant Name
Date
Employee Name
S.S. #
Job Title
Birthdate:
Age:
Sex:
Height:
Weight:
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