PWS Att 1 - Laboratory Animal Allergy Questionnaire.pdf

Laboratory Animal Allergy Questionnaire

Date________________________

Name:___________________________________________

Supervisor:_______________________________________

Department:______________________________________________________________

Age:___________ Sex: ___Male ___Female

OCCUPATIONAL HISTORY

Answer these questions about your present job:

Job title:______________________________________________________ Number of years employed at this facility:________ How many months/years at your present position?______

Brief description of duties

Do you work with laboratory animals? ___Yes ___No If yes, complete the following.

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 ___ Yes ___ No Gloves ___ Yes ___ No

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?

___ Yes ___ No

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

___ Yes ___ No

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

___ Yes ___ No

Are you under a doctors care for any other illnesses?

___ Yes ___ No

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

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:___________________