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