Attach_5_Occupational_Health_Questionnaire_-_Physical_Exam.doc

DOC document 260 KB Posted Sep 27, 2018

Attached to: Morgantown NIOSH Medical Services
Solicitation number: 75D301-18-Q-69353
Issued by: Department of Health and Human Services Centers for Disease Control and Prevention Pittsburgh

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The National Institute for Occupational Safety and Health has established an institute-wide surveillance program to reduce insofar as possible the health risks of its employees who may be potentially exposed to hazardous materials. The attached confidential health questionnaire has been designed to elicit general and specific information concerning your health. While this information is essential in determining your health status, it also represents an opportunity to express your concerns regarding your occupational environment. Your answers will allow the medical staff to determine those tests and procedures most appropriate to your particular work situation. This questionnaire will become an important part of our medical surveillance program records. This program represents a valuable job benefit and we urge you to participate. When you have finished your questionnaire, hand it directly to the doctor or nurse, or if mailed, mark the envelope “TO BE OPENED BY MEDICAL OFFICER ONLY”.

CENTERS FOR DISEASE CONTROL AND PREVENTION

NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH

OCCUPATIONAL HEALTH QUESTIONNAIRE

CONFIDENTIAL:

FOR MEDICAL USE ONLY

Today's date:

Name:

Sex:

Birthdate:

CDC-NIOSH organizational unit:

Location:

Job Title or Category:

Years in present position:

Regular Workplace: bldg: H or L Room no:

Phone no:

Marital Status:

Brief description of duties:

A. Please answer the following questions by checking the applicable blocks:

Have you ever been hospitalized?

NO FORMCHECKBOX

YES FORMCHECKBOX

If yes, give details and dates:

Have you ever had any operation(s)?

If yes, give details and dates:

Indicate any occupational illnesses or injuries you have experienced since being employed by CDC-NIOSH:

Have you ever been a resident outside the United States:

If yes, please list location(s) and date(s):

Have you ever served in the armed forces or merchant marines? NO FORMCHECKBOX

If yes, indicate geographic areas of duty and dates:

Please make a list of those substances that you now handle in your work, hobbies, or pastime. Star (*) those that particularly concern you from a health standpoint:

Have you ever worked with any other substance which you think might be or may have been hazardous (please list)?

Do you have or have you made any suggestions to reduce potential exposures?

Indicate any signs or symptoms that you have or have experienced that might be due to exposure at work and indicate the suspected cause:

B. In your work now or have you ever been exposed to any of the following agents?

Exposure

Present

Past

Unknown

Minimal

Moderate

Excessive

Inorganic Fluorides

FORMCHECKBOX

Lead

FORMCHECKBOX

Benzene

FORMCHECKBOX

Coke Oven Emissions

FORMCHECKBOX

Inorganic Arsenic

FORMCHECKBOX

Methylene Chloride

FORMCHECKBOX

Vinyl Chloride

FORMCHECKBOX

Toluene Diisocyanate

FORMCHECKBOX

Excessive Noise

FORMCHECKBOX

Nitrogen Oxides

FORMCHECKBOX

Crystalline Silica

FORMCHECKBOX

Nitric Acid

FORMCHECKBOX

Ammonia

FORMCHECKBOX

Beryllium

FORMCHECKBOX

Phosgene

FORMCHECKBOX

Allyl Chloride

FORMCHECKBOX

Asbestos

FORMCHECKBOX

Suspect or Known Carcinogens

FORMCHECKBOX

Pesticides

FORMCHECKBOX

Bacteria or Viruses

FORMCHECKBOX

Primate Animals

FORMCHECKBOX

Vibrating Tools

FORMCHECKBOX

Radiation (Specify Ionization, Non-Ionizing or Both)

FORMCHECKBOX

C. Do you have or have you had any of the following? If so, please check the appropriate boxes.

FORMCHECKBOX

allergies

FORMCHECKBOX

back pain blood in urine, sputum or stool blood pressure changes

FORMCHECKBOX

bowel changes

FORMCHECKBOX

cancer

FORMCHECKBOX

chest pain

FORMCHECKBOX

chronic cough

FORMCHECKBOX

cold or painful fingers

FORMCHECKBOX

dental or gum problems

FORMCHECKBOX

depression or excessive worry

FORMCHECKBOX

diabetes

FORMCHECKBOX

diarrhea

FORMCHECKBOX

difficulty in sleeping

FORMCHECKBOX

dizziness

FORMCHECKBOX

ear or hearing problems edema (feet or legs swelling) eye trouble (other than corrective lenses)

FORMCHECKBOX

fainting spells or unconsciousness

FORMCHECKBOX

fever of unknown origin

FORMCHECKBOX

frequent indigestion or stomach trouble

FORMCHECKBOX

frequent or severe headaches heart problems (fast beat, murmurs, pain, etc.)

hemorrhoids (piles)

FORMCHECKBOX

hives or skin rash

FORMCHECKBOX

hot flashes or flushing

FORMCHECKBOX

joint pains

FORMCHECKBOX

kidney problems

FORMCHECKBOX

leg cramps

FORMCHECKBOX

liver problems

FORMCHECKBOX

loss of or poor memory

FORMCHECKBOX

lung problems or breathing difficulty

FORMCHECKBOX

menopause symptoms

FORMCHECKBOX

muscle aches or pains

FORMCHECKBOX

nervousness or irritability

FORMCHECKBOX

sexual problems

FORMCHECKBOX

sickle cell disease or trait

FORMCHECKBOX

skin disease or problems

FORMCHECKBOX

swollen glands (groin, underarm, neck)

FORMCHECKBOX

thyroid gland problem

FORMCHECKBOX

tremor of hands or head

FORMCHECKBOX

tumors, cysts, or mass

FORMCHECKBOX

unexpected weight changes

FORMCHECKBOX

unusual weakness or fatigue

FORMCHECKBOX

venereal disease

D. Family History Indicate any blood relatives that you know of who ever had any of the following:

Relationship to You

Disease

Mother

Father

Grandparent

Brother/Sister

My children

Anemia

FORMCHECKBOX

Arthritis

FORMCHECKBOX

Allergy (asthma, eczema, hay fever)

FORMCHECKBOX

Alcoholism

FORMCHECKBOX

Bleeding disorders

FORMCHECKBOX

Congenital malformations or abnormalities

FORMCHECKBOX

Cancer

FORMCHECKBOX

Diabetes

FORMCHECKBOX

Emphysema

FORMCHECKBOX

Epilepsy

FORMCHECKBOX

Glaucoma (incl. Eye pressures)

FORMCHECKBOX

Gout or painful joints

FORMCHECKBOX

Heart problems

FORMCHECKBOX

High blood pressure

FORMCHECKBOX

Disease

Mother

Father

Grandparent

Brother/Sister

My children

Kidney disease or stones

FORMCHECKBOX

Gall bladder problems

FORMCHECKBOX

Mental problems

FORMCHECKBOX

Sickle cell disease or trait

FORMCHECKBOX

Stomach problems

FORMCHECKBOX

Stroke

FORMCHECKBOX

Tuberculosis

FORMCHECKBOX

Other (specify)

FORMCHECKBOX

E. Do you work with laboratory animals? ___Yes ___No If yes, complete the following. If no, skip to section F.

Animal

Yes No Approximate Contact Hours/Day

Rats

Mice

Rabbits

Guinea Pigs

Other

Do you feel that you are allergic to any of these animals? ___ Yes ___ No

___ Rats ___ Mice ___ Rabbits ___ Dogs ___ Other

___ Cats ___ Monkeys ___ Cattle ___ Guinea Pigs

Did you work with laboratory animals before your employment at this facility?

___ Yes ___ No

If yes, how long?_____ years What type of animals? ______________________

Do you use or wear any of the following items when working with animals?

Protective Eye Glasses ___ Yes ___ No

Mask/Respirator

___ Yes ___ No

Lab Coat

Gloves

HOME ENVIRONMENT INFORMATION

Do you have any indoor pets? ___ Yes ___ No If yes, which animals and for how long?

Animal

1-2 Years 2-3 Years 3-4 Years Over 4 Years

Dogs

Cats

Other (Type)__________

Do you regularly have any of the following symptoms? ___ Yes ___ No Please indicate if the symptom is present and the year of onset. Also check in what location or time “period” the symptom(s) is/are present.

Yes/No Year of Symptoms Are Present

Symptom

Present Onset

At Work At Home On Vacation No Difference

Cough

Sputum Production

Shortness of Breath

Wheezing

Chest Tightness

Asthma

Nose Congestion

Runny Nose

Sneezing

Itchy Eyes

Sinus Problems

Hay Fever

Frequent Colds

Hives

Skin Rash

Swelling of Eyes or Lips

Eczema

Difficulty in Swallowing

Were you ever told by a doctor that you had allergies? ___ Yes ___ No

Have you ever been skin tested for allergies? ___ Yes ___ No If yes, what substances were you found to be allergic to or sensitized to?

___ Ragweed ___ Grass ___ Trees ___ Mold ___ Dust ___ Cat ___ Dog ___ Mice ___

Other _____________________________________________________________

Have you ever received allergy (desensitization/immunotherapy) shots? ___ Yes ___ No

Has a doctor ever said you have asthma? ___ Yes ___ No

If yes, when did your asthma start? __________ (year)

Are you currently taking medication (either over the counter or by prescription) to control your asthma?

Has a doctor ever told you that you have a medical condition caused by your working conditions?

Do any of your blood relatives (grandparents, parents, brothers/sisters) have allergies or asthma?

Are you under a doctors care for any other illnesses?

If yes, please list illnesses: _____________________________________________________________________________

Do you take blood pressure medication(s)? ___ Yes ___ No

Do you regularly use “over the counter” (nonprescription) nose drops or nose sprays (e.g., Afrin, Neosynephrine)? ___ Yes ___ No

Do you smoke cigarettes? ___ Yes ___ No If yes, how many cigarettes per day?________

How many years?_______

If not presently smoking, did you ever smoke? ___ Yes ___ No

If yes, when did you stop smoking cigarettes? _________ (year)

How many years did you smoke? __________ years

Comments

F. If either of your parents are dead list their age at death and cause of death, if known:

mother died at age of father died at age of

Are you aware of any diseases or illnesses that run in your family or are common?

If yes, please list:

G. During a typical week, on approximately how many days do you drink alcoholic beverages?

days (mark 0 if you do not drink alcoholic beverages)

If you drink, do you ever drink on those days when you work?

NO FORMCHECKBOX

YES FORMCHECKBOX

If "yes," do you normally drink....?

FORMCHECKBOX

before going to work after finishing work during lunch breaks during rest breaks when at work

On those days when you do drink, about how many of each of the following do you usually drink? (mark 0 if you do not drink alcoholic beverages.):

bottles of beer glasses of wine shots of liquor (shot = 1 1/2 oz.)

Would you say that the amount of alcohol have been drinking lately has…?

FORMCHECKBOX

increased

FORMCHECKBOX

decreased

FORMCHECKBOX

remained about the same

FORMCHECKBOX

don't drink

Would you say that you use alcohol to help you get to sleep...?

FORMCHECKBOX

frequently

FORMCHECKBOX

occasionally

FORMCHECKBOX

seldom

FORMCHECKBOX

never

H. Do you smoke:

NO FORMCHECKBOX

YES FORMCHECKBOX

If no, are you a former smoker?

NO FORMCHECKBOX

YES FORMCHECKBOX

If yes, how long ago did you quit?

years

How many years did you smoke before quitting?

years

How much were you smoking before you quit? That is, number of cigarettes, cigars, or pipes smoked per day?

If yes, please answer the following:

How long have you smoked?

years

How many of the following do you smoke per day?

cigarettes pipefuls of tobacco cigars

Would you say that your amount of smoking lately has . . .? (check one) increased

FORMCHECKBOX

decreased

FORMCHECKBOX

remained the same

I. How much sleep would you like to get every 24 hours?

hours

About how much sleep do you actually get during every 24 hours?

hours

How long does it usually take for you to get to sleep?

minutes

How often do you wake up tired or sleepy? (check one)

FORMCHECKBOX

not at all

FORMCHECKBOX

occasionally

FORMCHECKBOX

frequently

FORMCHECKBOX

always

How often do you feel tired or sleepy at work? (check one) never once a week less than once per month

2 or 3 times a week once or twice a month

FORMCHECKBOX

about every day

About how often do you feel tired or sleepy after completing your work? (check one) never once a week less than once per month

2 or 3 times a week once or twice a month

FORMCHECKBOX

about every day

J. Here are some items about how people may feel. When you think about yourself and your job nowadays, how much of the time do you feel this way? (please answer all of the items)

Never or a little of the time

Some of the time

A good part of the time

Most of the time

I feel happy

FORMCHECKBOX

I feel unhappy

FORMCHECKBOX

I feel good

FORMCHECKBOX

I feel depressed

FORMCHECKBOX

I feel blue

FORMCHECKBOX

I feel cheerful

FORMCHECKBOX

I feel nervous

FORMCHECKBOX

I feel calm

FORMCHECKBOX

I feel fidgety

FORMCHECKBOX

K. Have you ever had or do you now have any of the following illnesses or conditions? If so, pleas check the appropriate blank(s):

abnormal bleeding

FORMCHECKBOX

anemia

FORMCHECKBOX

arthritis

FORMCHECKBOX

asthma

FORMCHECKBOX

bends

FORMCHECKBOX

cancer

FORMCHECKBOX

cirrhosis of the liver

FORMCHECKBOX

dermatitis

FORMCHECKBOX

diabetes

FORMCHECKBOX

dizziness or fainting

FORMCHECKBOX

epilepsy

FORMCHECKBOX

erysipelas

FORMCHECKBOX

gall bladder/stones

FORMCHECKBOX

glaucoma

FORMCHECKBOX

gonorrhea gout hay fever

FORMCHECKBOX

heart attack or trouble

FORMCHECKBOX

hepatitis

FORMCHECKBOX

hernia or rupture high blood pressure hives jaundice

FORMCHECKBOX

kidney trouble or stones

FORMCHECKBOX

leukemia

FORMCHECKBOX

malaria

FORMCHECKBOX

migraine

FORMCHECKBOX

mumps

FORMCHECKBOX

nephritis (Bright's disease)

FORMCHECKBOX

nervous breakdown

FORMCHECKBOX

neuritis

FORMCHECKBOX

paralysis of any type

FORMCHECKBOX

piles or hemorrhoids

FORMCHECKBOX

pneumonia

FORMCHECKBOX

polio

FORMCHECKBOX

rheumatic fever

FORMCHECKBOX

scarlet fever

FORMCHECKBOX

stroke

FORMCHECKBOX

swollen joints

FORMCHECKBOX

syphilis

FORMCHECKBOX

tuberculosis

FORMCHECKBOX

ulcer (stomach or duodenal)

L. Females only *

*Number of normal pregnancies

*Number of living children

*Number of involuntary miscarriages

*Date of last pap test

*Date of last period

*Have you had any unusual discharge or bleeding in the past three months?

*Have you had any unusual discharge or bleeding at any time?

*Have you reached menopause?

Have you or your present or former spouse had any adverse reproductive outcome? For example: stillborn, deformed, irregular menses?

YES FORMCHECKBOX

M. Medication History Are you now taking or have you taken any of the following drugs within the past month? (specify drug)

FORMCHECKBOX

antacids

FORMCHECKBOX

antibiotics

FORMCHECKBOX

anticoagulant (blood thinner)

FORMCHECKBOX

antidepressants antihistamines appetite depressants aspirin benzedrine birth control medication blood pressure medication codeine cortisone or steroids dexedrine digitalis

FORMCHECKBOX

diuretic

FORMCHECKBOX

hormones

FORMCHECKBOX

insulin or oral anti-diabetic drug

FORMCHECKBOX

laxatives

FORMCHECKBOX

minerals

FORMCHECKBOX

morphine

FORMCHECKBOX

sleeping pills

FORMCHECKBOX

sulfa preparations

FORMCHECKBOX

thyroid

FORMCHECKBOX

tranquilizers

FORMCHECKBOX

vitamins

List drugs you take regularly:

N. Have you been on any diet(s) in the past year?

if yes, describe type (for overweight, underweight, diabetic, etc.):

O. Are you allergic to any of the following? (check appropriate blank)

FORMCHECKBOX

pollens

FORMCHECKBOX

house dust

FORMCHECKBOX

animal dander, feathers, or fur

FORMCHECKBOX

drugs

FORMCHECKBOX

vaccines

FORMCHECKBOX

serum

FORMCHECKBOX

metal, jewelry

FORMCHECKBOX

foods

FORMCHECKBOX

sunlight, cold, heat

FORMCHECKBOX

other

If yes, please provide details:

P. Immunization, vaccines, antitoxins, etc.

Check if you have received any of the following. Give approximate date(s) when last received, if known:

Dates

FORMCHECKBOX

tetanus

FORMCHECKBOX

poliomyelitis

FORMCHECKBOX

influenza

FORMCHECKBOX

typhoid

FORMCHECKBOX

diphtheria

FORMCHECKBOX

rabies

FORMCHECKBOX

rabies

FORMCHECKBOX

rubella (german measles)

FORMCHECKBOX

measles (rubella or red measles)

FORMCHECKBOX

bcg

FORMCHECKBOX

yellow fever

FORMCHECKBOX

anthrax

FORMCHECKBOX

small pox

FORMCHECKBOX

rhogam (rh immune globulin)

FORMCHECKBOX

immune serum globulin (for hepatitis)

FORMCHECKBOX

others (please list)

FORMCHECKBOX

mantoux, patch test, or other skin test for tuberculosis. Give date and result of first test, if known Date Result:

positive negative

When you have finished this medical and occupational history form, hand it directly to the doctor or nurse, or if mailed, mark envelope "to be opened by medical personnel."

INTERIM MEDICAL AND OCCUPATIONAL HISTORY

CONFIDENTIAL

FOR MEDICAL USE ONLY

Are you still performing the same job that you were performing when you had your last annual physical examination?

NO FORMCHECKBOX

YES FORMCHECKBOX

Were you notified of the results of the medical findings and laboratory results from your previous physical examination?

NO FORMCHECKBOX

YES FORMCHECKBOX

Have you been exposed to any toxic substances above OSHA standards in your work, hobbies or pastime since your last physical examination?

NO FORMCHECKBOX

YES FORMCHECKBOX

Have you been exposed to any excessive psychological job-stress or strain in the past year?

NO FORMCHECKBOX

YES FORMCHECKBOX

Have you or your spouse (present or former) had any adverse reproductive outcome in the past year?

NO FORMCHECKBOX

YES FORMCHECKBOX

Have you experience any immunization, vaccines, antitoxins, or allergy reactions in the past year?

NO FORMCHECKBOX

YES FORMCHECKBOX

Have you consulted a private physician for reasons that are work-related in the past year?

NO FORMCHECKBOX

YES FORMCHECKBOX

Comments on any of the above questions or other medical problems you may have should be made on additional sheets of paper.

Employee's Signature:

Date:

Medical officer's comments:

Laboratory Animal Allergy Questionnaire

Medical recommendation

Employee

□ The employee is cleared for contact with the research animals.

□ The employee is cleared for contact with the research animals with the following restrictions:

□ The employee is not cleared for contact with the research animals.

Reviewed By:______________________________________ Date:___________________

PAGE

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