A. Identification

Plant Name____________________________________________________________
Date__________________________________________________________________
Employee Name_________________________________________________________
S.S. #________________________________________________________________
Job Title_____________________________________________________________
Birthdate:____________________________________________________________
Age:__________________________________________________________________
Sex:__________________________________________________________________
Height:_______________________________________________________________
Weight:_______________________________________________________________

B. Medical History

1. Have you ever been in the hospital as a patient?
Yes__ No__
If yes, what kind of problem were you having?___________________________
________________________________________________________________________
2. Have you ever had any kind of operation?
Yes__ No__
If yes, what kind?______________________________________________________
________________________________________________________________________
3. Do you take any kind of medicine regularly?
Yes__ No__
If yes, what kind?______________________________________________________
________________________________________________________________________
4. Are you allergic to any drugs, foods, or chemicals?
Yes__ No__
If yes, what kind of allergy is it?_____________________________________
________________________________________________________________________
What causes the allergy?________________________________________________
________________________________________________________________________
5. Have you ever been told that you have asthma, hayfever, or sinusitis?
Yes__ No__
6. Have you ever been told that you have emphysema, bronchitis, or any
other respiratory problems?
Yes__ No__
7. Have you ever been told you had hepatitis?
Yes__ No__
8. Have you ever been told that you had cirrhosis?
Yes__ No__
9. Have you ever been told that you had cancer?
Yes__ No__
10. Have you ever had arthritis or joint pain?
Yes__ No__
11. Have you ever been told that you had high blood pressure?
Yes__ No__
12. Have you ever had a heart attack or heart trouble?
Yes__ No__

B-1. Medical History Update

1. Have you been in the hospital as a patient any time within the past
year?
Yes__ No__
If so, for what condition?______________________________________________
________________________________________________________________________
2. Have you been under the care of a physician during the past year?
Yes__ No__
If so, for what condition?______________________________________________
________________________________________________________________________
3. Is there any change in your breathing since last year?
Yes__ No__
Better?_________________________________________________________________
Worse?__________________________________________________________________
No change?______________________________________________________________
If change, do you know why?_____________________________________________
________________________________________________________________________
4. Is your general health different this year from last year?
Yes__ No__
If different, in what way?______________________________________________
________________________________________________________________________
5. Have you in the past year or are you now taking any medication on a
regular basis?
Yes__ No__
Name Rx_________________________________________________________________
Condition being treated ________________________________________________

C. Occupational History

1. How long have you worked for your present employer?
________________________________________________________________________
2. What jobs have you held with this employer? Include job title and
length of time in each job.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
3. In each of these jobs, how many hours a day were you exposed to
chemicals?
________________________________________________________________________
4. What chemicals have you worked with most of the time?
________________________________________________________________________
5. Have you ever noticed any type of skin rash you feel was related to
your work?
Yes__ No__
6. 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__
7. Are you exposed to any dust or chemicals at home?
Yes__ No__
If yes, explain:________________________________________________________
________________________________________________________________________
8. 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

1. Are you working on the same job this year as you were last year?
Yes__ No__
If not, how has your job changed?_______________________________________
________________________________________________________________________
2. What chemicals are you exposed to on your job?
________________________________________________________________________
3. How many hours a day are you exposed to chemicals?
________________________________________________________________________
4. Have you noticed any skin rash within the past year you feel was
related to your work?
Yes__ No__
If so, explain circumstances:___________________________________________
________________________________________________________________________
5. Have you noticed that any chemical makes you cough, be short of
breath, or wheeze?
Yes__ No__
If so, can you identify it?_____________________________________________
________________________________________________________________________

D. Miscellaneous

1. Do you smoke?
Yes__ No__
If so, how much and for how long?_______________________________________
________________________________________________________________________
Pipe____________________________________________________________________
Cigars__________________________________________________________________
Cigarettes______________________________________________________________
2. Do you drink alcohol in any form?
Yes__ No__
If so, how much, how long, and how often?_______________________________
________________________________________________________________________
3. Do you wear glasses or contact lenses?
Yes__ No__
4. Do you get any physical exercise other than that required to do your
job?
Yes__ No__
If so, explain:_________________________________________________________
________________________________________________________________________
5. 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.
________________________________________________________________________

E. Symptoms Questionnaire

1. 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__
2. 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__
3. 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__
4. 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?_____________________________________________________
5. Have you noticed any burning, tearing, or redness of your eyes when
you are at work?
Yes__ No__
If so, explain circumstances:___________________________________________
________________________________________________________________________
6. Have you noticed any sore or burning throat or itchy or burning nose
when you are at work?
Yes__ No__
If so, explain circumstances:___________________________________________
________________________________________________________________________
7. Have you noticed any stuffiness or dryness of your nose?
Yes__ No__
8. Do you ever have swelling of the eyelids or face?
Yes__ No__
9. Have you ever been jaundiced?
Yes__ No__
If yes, was this accompanied by any pain?
Yes__ No__
10. Have you ever had a tendency to bruise easily or bleed excessively?
Yes__ No__
11. 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?_____________________________________________
________________________________________________________________________
12. Do you have frequent episodes of nervousness or irritability?
Yes__ No__
13. Do you tend to have trouble concentrating or remembering?
Yes__ No__
14. Do you ever feel dizzy, light-headed, excessively drowsy or like you
have been drugged?
Yes__ No__
15. Does your vision ever become blurred?
Yes__ No__
16. Do you have numbness or tingling of the hands or feet or other parts
of your body?
Yes__ No__
17. Have you ever had chronic weakness or fatigue?
Yes__ No__
18. Have you ever had any swelling of your feet or ankles to the point
where you could not wear your shoes?
Yes__ No__
19. Are you bothered by heartburn or indigestion?
Yes__ No__
20. Do you ever have itching, dryness, or peeling and scaling of the
hands?
Yes__ No__
21. Do you ever have a burning sensation in the hands, or reddening of
the skin?
Yes__ No__
22. Do you ever have cracking or bleeding of the skin on your hands?
Yes__ No__
23. Are you under a physician's care?
Yes__ No__
If yes, for what are you being treated?_________________________________
________________________________________________________________________
24. Do you have any physical complaints today?
Yes__ No__
If yes, explain?________________________________________________________
________________________________________________________________________
25. Do you have other health conditions not covered by these questions?
Yes__ No__
If yes, explain:________________________________________________________
________________________________________________________________________