Please sign below. |
I have read these directions and understand them: |
Employee signature |
Date |
Thank you for answering these questions. (Suggested Format) |
Name . . . . |
Age . . . . |
Social Security # . . . . |
Company . . . . |
Job . . . . |
Type of Preplacement Exam: [ ] Periodic [ ] Termination [ ] Initial [ ] Other |
Blood Pressure . . . . |
Pulse Rate . . . . |
1. How long have you worked at the job listed above? |
[ ] Not yet hired [ ] Number of months [ ] Number of years |
2. Job Duties etc. |
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3. Have you ever been told by a doctor that you had bronchitis? [ ] Yes [ ] No If yes, how long ago? [ ] Number of months [ ] Number of years |
4. Have you ever been told by a doctor that you had emphysema? [ ] Yes [ ] No If yes, how long ago? [ ] Number of years [ ] Number of months |
5. Have you ever been told by a doctor that you had other lung problems? [ ] Yes [ ] No If yes, please describe type of lung problems and when you had these problems |
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6. In the past year, have you had a cough? [ ] Yes [ ] No If yes, did you cough up sputum? [ ] Yes [ ] No If yes, how long did the cough with sputum production last? [ ] Less than 3 months [ ] 3 months or longer If yes, for how many years have you had episodes of cough with sputum production lasting this long? [ ] Less than one [ ] 1 [ ] 2 [ ] Longer than 2 |
7. Have you ever smoked cigarettes? [ ] Yes [ ] No |
8. Do you now smoke cigarettes? [ ] Yes [ ] No |
9. If you smoke or have smoked cigarettes, for how many years have you smoked, or did you smoke? [ ] Less than 1 year [ ] Number of years What is or was the greatest number of packs per day that you have smoked? [ ] Number of packs If you quit smoking cigarettes, how many years ago did you quit? [ ] Less than 1 year [ ] Number of years How many packs a day do you now smoke? [ ] Number of packs per day |
10. Have you ever been told by a doctor that you had a kidney or urinary tract disease or disorder? [ ] Yes [ ] No |
11. Have you ever had any of these disorders? Kidney stones [ ] Yes [ ] No Protein in urine [ ] Yes [ ] No Blood in urine [ ] Yes [ ] No Difficulty urinating [ ] Yes [ ] No Other kidney/Urinary disorders [ ] Yes [ ] No Please describe problems, age, treatment, and follow up for any kidney or urinary problems you have had: |
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12. Have you ever been told by a doctor or other health care provider who took your blood pressure that your blood pressure was high? [ ] Yes [ ] No |
13. Have you ever been advised to take any blood pressure medication? [ ] Yes [ ] No |
14. Are you presently taking any blood pressure medication? [ ] Yes [ ] No |
15. Are you presently taking any other medication? [ ] Yes [ ] No |
16. Please list any blood pressure or other medications and describe how long you have been taking each one: |
Medicine: |
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How Long Taken |
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17. Have you ever been told by a doctor that you have diabetes? (sugar in your blood or urine) [ ] Yes [ ] No If yes, do you presently see a doctor about your diabetes? [ ] Yes [ ] No If yes, how do you control your blood sugar? [ ] Diet alone [ ] Diet plus oral medicine [ ] Diet plus insulin (injection) |
18. Have you ever been told by a doctor that you had: Anemia [ ] Yes [ ] No A low blood count? [ ] Yes [ ] No |
19. Do you presently feel that you tire or run out of energy sooner than normal or sooner than other people your age? [ ] Yes [ ] No If yes, for how long have you felt that you tire easily? [ ] Less than 1 year [ ] Number of years |
20. Have you given blood within the last year? [ ] Yes [ ] No If yes, how many times? [ ] Number of times How long ago was the last time you gave blood? [ ] Less than 1 month [ ] Number of months |
21. Within the last year have you had any injuries with heavy bleeding? [ ] Yes [ ] No If yes, how long ago? [ ] Less than 1 month [ ] Number of months describe: . . . . |
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22. Have you recently had any surgery? [ ] Yes [ ] No If yes, please describe: . . . . |
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23. Have you seen any blood lately in your stool or after a bowel movement? [ ] Yes [ ] No |
24. Have you ever had a test for blood in your stool? [ ] Yes [ ] No If yes, did the test show any blood in the stool? [ ] Yes [ ] No What further evaluation and treatment were done? . . . . |
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The following questions pertain to the ability to wear a respirator. Additional information for the physician can be found in The Respiratory Protective Devices Manual. |
25. Have you ever been told by a doctor that you have asthma? [ ] Yes [ ] No If yes, are you presently taking any medication for asthma? Mark all that apply. [ ] Shots [ ] Pills [ ] Inhaler |
26. Have you ever had a heart attack? [ ] Yes [ ] No If yes, how long ago? [ ] Number of years [ ] Number of months |
27. Have you ever had pains in your chest? [ ] Yes [ ] No If yes, when did it usually happen? [ ] While resting [ ] While working [ ] While exercising [ ] Activity didn't matter |
28. Have you ever had a thyroid problem? [ ] Yes [ ] No |
29. Have you ever had a seizure or fits? [ ] Yes [ ] No |
30. Have you ever had a stroke (cerebrovascular accident)? [ ] Yes [ ] No |
31. Have you ever had a ruptured eardrum or a serious hearing problem? [ ] Yes [ ] No |
32. Do you now have a claustrophobia, meaning fear of crowded or closed in spaces or any psychological problems that would make it hard for you to wear a respirator? [ ] Yes [ ] No The following questions pertain to reproductive history. |
33. Have you or your partner had a problem conceiving a child? [ ] Yes [ ] No If yes, specify: [ ] Self [ ] Present mate [ ] Previous mate |
34. Have you or your partner consulted a physician for a fertility or other reproductive problem? [ ] Yes [ ] No If yes, specify who consulted the physician: [ ] Self [ ] Spouse/partner [ ] Self and partner If yes, specify diagnosis made: . . . . |
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35. Have you or your partner ever conceived a child resulting in a miscarriage, still birth or deformed offspring? [ ] Yes [ ] No If yes, specify: [ ] Miscarriage [ ] Still birth [ ] Deformed offspring If outcome was a deformed offspring, please specify type: . . . . |
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36. Was this outcome a result of a pregnancy of: [ ] Yours with present partner [ ] Yours with a previous partner |
37. Did the timing of any abnormal pregnancy outcome coincide with present employment? [ ] Yes [ ] No List dates of occurrences: . . . . |
38. What is the occupation of your spouse or partner? |
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For Women Only |
39. Do you have menstrual periods? [ ] Yes [ ] No Have you had menstrual irregularities? [ ] Yes [ ] No If yes, specify type: . . . . |
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If yes, what was the approximated date this problem began? Approximate date problem stopped? . . . . |
For Men Only |
40. Have you ever been diagnosed by a physician as having prostate gland problem(s)? [ ] Yes [ ] No If yes, please describe type of problem(s) and what was done to evaluate and treat the problem(s): . . . . |
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