PWS Att 5 -Occ Health Assessment.pdf

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 YES If yes, give details and dates:

Have you ever had any operation(s)? NO YES 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: NO YES If yes, please list location(s) and date(s):

Have you ever served in the armed forces or merchant marines? NO YES 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 Lead Benzene Coke Oven Emissions Inorganic Arsenic Methylene Chloride Vinyl Chloride Toluene Diisocyanate Excessive Noise Nitrogen Oxides Crystalline Silica Nitric Acid Ammonia Beryllium Phosgene Allyl Chloride Asbestos Suspect or Known Carcinogens

Pesticides Bacteria or Viruses Primate Animals Vibrating Tools Radiation (Specify Ionization, Non-Ionizing or Both)

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

allergies back pain blood in urine, sputum or stool blood pressure changes bowel changes cancer chest pain chronic cough cold or painful fingers dental or gum problems depression or excessive worry diabetes diarrhea difficulty in sleeping dizziness ear or hearing problems edema (feet or legs swelling) eye trouble (other than corrective lenses) fainting spells or unconsciousness fever of unknown origin frequent indigestion or stomach trouble frequent or severe headaches heart problems (fast beat, murmurs, pain, etc.)

hemorrhoids (piles) hives or skin rash hot flashes or flushing joint pains kidney problems leg cramps liver problems loss of or poor memory lung problems or breathing difficulty menopause symptoms muscle aches or pains nervousness or irritability sexual problems sickle cell disease or trait skin disease or problems swollen glands (groin, underarm, neck) thyroid gland problem tremor of hands or head tumors, cysts, or mass unexpected weight changes unusual weakness or fatigue 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 Arthritis Allergy (asthma, eczema, hay fever)

Alcoholism Bleeding disorders Congenital malformations or abnormalities

Cancer Diabetes Emphysema Epilepsy Glaucoma (incl. Eye pressures) Gout or painful joints Heart problems High blood pressure

Disease Mother Father Grandparent Brother/ Sister

My children

Kidney disease or stones Gall bladder problems Mental problems Sickle cell disease or trait Stomach problems Stroke Tuberculosis Other (specify)

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 ___ 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

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?

NO YES

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?

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

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…?

increased decreased remained about the same don't drink

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

frequently occasionally seldom never

H. Do you smoke: NO YES

If no, are you a former smoker? NO YES

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 decreased 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) not at all occasionally frequently 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 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 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 I feel unhappy

Never or a little of the time

Some of the time

A good part of the time

Most of the time

I feel good I feel depressed I feel blue I feel cheerful I feel nervous I feel calm I feel fidgety

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 anemia arthritis asthma bends cancer cirrhosis of the liver dermatitis diabetes dizziness or fainting epilepsy erysipelas gall bladder/stones glaucoma gonorrhea gout hay fever heart attack or trouble hepatitis hernia or rupture high blood pressure hives jaundice kidney trouble or stones leukemia malaria migraine mumps nephritis (Bright's disease) nervous breakdown neuritis paralysis of any type piles or hemorrhoids pneumonia polio rheumatic fever scarlet fever stroke swollen joints syphilis tuberculosis 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? NO YES

*Have you reached menopause? NO YES

Have you or your present or former spouse had any adverse reproductive outcome? For example: stillborn, deformed, irregular menses? NO YES

M. Medication History

Are you now taking or have you taken any of the following drugs within the past month? (specify drug) antacids antibiotics anticoagulant (blood thinner) antidepressants antihistamines appetite depressants aspirin benzedrine birth control medication blood pressure medication codeine cortisone or steroids dexedrine digitalis diuretic hormones insulin or oral anti-diabetic drug laxatives minerals morphine sleeping pills sulfa preparations thyroid tranquilizers vitamins

List drugs you take regularly:

N. Have you been on any diet(s) in the past year? NO YES if yes, describe type (for overweight, underweight, diabetic, etc.):

O. Are you allergic to any of the following? (check appropriate blank) pollens house dust animal dander, feathers, or fur drugs vaccines serum metal, jewelry foods sunlight, cold, heat 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 tetanus poliomyelitis influenza typhoid diphtheria rabies rabies rubella (german measles) measles (rubella or red measles) bcg yellow fever anthrax small pox rhogam (rh immune globulin) immune serum globulin (for hepatitis) others (please list) 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

1. Are you still performing the same job that you were performing when you had your last annual physical examination? NO YES

2. Were you notified of the results of the medical findings and laboratory results from your previous physical examination? NO YES

3. Have you been exposed to any toxic substances above OSHA standards in your work, hobbies or pastime since your last physical examination? NO YES

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

5. Have you or your spouse (present or former) had any adverse reproductive outcome in the past year? NO YES

6. Have you experience any immunization, vaccines, antitoxins, or allergy reactions in the past year? NO YES

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

8. 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:___________________