B.06.05 Attachment 4 - Asbestos Exposure, Part I - Initial Medical Questionnaire.pdf

ASBESTOS EXPOSURE

PART I - INITIAL MEDICAL QUESTIONNAIRE

IDENTIFICATION

1. NAME (Last, First, Middle Initial) 2. SOCIAL SECURITY NO. (1 - 9) 3. CLOCK NO. (10 - 15) 4. PRESENT OCCUPATION

5. NAME OF PLANT 6. STREET ADDRESS OF PLANT 7. PLANT CITY, STATE AND ZIP CODE

8. TELEPHONE NO.

(Include area code)

9. NAME OF INTERVIEWER 10. DATE OF INTERVIEW

(16 - 21) (YYYYMMDD)

11. DATE OF BIRTH

(22 - 29) (YYYYMMDD)

12. PLACE OF BIRTH

13. SEX (X one)

a. MALE

b. FEMALE

14. MARITAL STATUS (X one)

a. SINGLE

c. WIDOWED

b. MARRIED

d. DIVORCED/SEPARATED

15. RACE (X one)

a. WHITE

d. HISPANIC

b. BLACK

e. INDIAN

c. ASIAN

f. OTHER

16. HIGHEST GRADE

COMPLETED IN

SCHOOL

MEDICAL DATA

17. OCCUPATIONAL HISTORY Yes No N/A

a. HAVE YOU EVER WORKED FULL TIME (30 hours per week or more)

FOR SIX MONTHS OR MORE?

b. IF YES, HAVE YOU EVER WORKED FOR A YEAR OR MORE IN ANY DUSTY JOB? *If Yes, complete (1) - (3).

(1) Specify Job/Industry (2) Total years worked MILD

MODERATE

SEVERE

(3) Dust Exposure (X one)

c. HAVE YOU EVER BEEN EXPOSED TO GAS OR CHEMICAL FUMES IN YOUR WORK? *If Yes, complete (1) - (3).

(1) Specify Job/ Industry (2) Total years worked MILD

MODERATE

SEVERE

(3) Exposure (X one)

d. WHAT HAS BEEN YOUR USUAL OCCUPATION - THE ONE YOU HAVE WORKED AT

THE LONGEST?

(1) Job/Occupation (2) Number of years employed in this occupation

(3) Position/Job Title (4) Business, Field or Industry

e. HAVE YOU EVER WORKED (X Yes or No and specify years worked, e.g. 1960 - 1969.) Years Worked

(1) In a mine

(2) In a quarry

(3) In a foundry

(4) In a pottery

(5) In a cotton, flax or hemp mill

(6) With asbestos

18. MEDICAL HISTORY

Yes No N/A

a. DO YOU CONSIDER YOURSELF TO BE IN GOOD HEALTH? *If No, state reason.

b. HAVE YOU ANY DEFECT OF VISION? *If Yes, state nature of defect.

c. HAVE YOU ANY HEARING DEFECT? *If Yes, state nature of defect.

d. ARE YOU SUFFERING FROM OR HAVE YOU EVER SUFFERED FROM

(1) Epilepsy (Or fits, seizures or convulsions)

(2) Rheumatic Fever

(3) Kidney Disease

(4) Bladder Disease

(5) Diabetes

(6) Jaundice

19. IF YOU GET A COLD, DOES IT USUALLY GO TO YOUR

CHEST? (Usually means more than 1/2 of the time)*Don't get colds

20. CHEST ILLNESSES

a. DURING THE PAST THREE YEARS, HAVE YOU HAD ANY

ILLNESSES THAT HAVE KEPT YOU OFF WORK, INDOORS AT HOME,

OR IN BED?

b. IF YES, DID YOU PRODUCE PHLEGM WITH ANY OF THESE

ILLNESSES?

c. IN THE LAST THREE YEARS, HOW MANY SUCH ILLNESSES WITH INCREASED PHLEGM DID YOU HAVE WHICH LASTED A WEEK OR MORE? (List number)

21. DID YOU HAVE ANY LUNG TROUBLE BEFORE THE AGE

OF 16?

22. HAVE YOU EVER HAD ANY OF THE FOLLOWING?

a. ATTACKS OF BRONCHITIS * If yes, complete (1) and (2).

(1) Age at first attack (2) Was it confirmed by a doctor?

b. ATTACKS OF PNEUMONIA (Include bronchopneumonia) *If yes, complete (1) and (2)

(1) Age at first attack (2) Was it confirmed by a doctor?

c. HAY FEVER * If yes, complete (1) and (2).

(1) Age at first attack (2) Was it confirmed by a doctor?

23. HAVE YOU EVER HAD CHRONIC BRONCHITIS?

a. IF YES, DO YOU STILL HAVE IT?

b. WAS IT CONFIRMED BY A DOCTOR?

c. AT WHAT AGE DID IT START? (List age)

24. HAVE YOU EVER HAD EMPHYSEMA?

a. IF YES, DO YOU STILL HAVE IT?

b. WAS IT CONFIRMED BY A DOCTOR?

c. AT WHAT AGE DID IT START? (List age)

25. HAVE YOU EVER HAD ASTHMA?

a. IF YES, DO YOU STILL HAVE IT?

b. WAS IT CONFIRMED BY A DOCTOR?

c. AT WHAT AGE DID IT START? (List age)

26. HAVE YOU EVER HAD:

a. ANY OTHER CHEST ILLNESSES *If yes, please specify.

b. ANY CHEST OPERATIONS *If yes, please specify.

c. ANY CHEST INJURIES *If yes, please specify.

d. IF YOU NO LONGER HAVE IT, AT WHAT AGE DID IT STOP? (List age)

27. HEART TROUBLE

a. HAS A DOCTOR EVER TOLD YOU THAT YOU HAD HEART TROUBLE?

b. IF YES, HAVE YOU EVER HAD TREATMENT FOR HEART TROUBLE IN

THE PAST TEN YEARS?

28. HIGH BLOOD PRESSURE

a. HAS A DOCTOR EVER TOLD YOU THAT YOU HAD HIGH BLOOD PRESSURE (Hypertension)?

b. IF YES, HAVE YOU EVER HAD TREATMENT FOR HIGH BLOOD

PRESSURE IN THE PAST TEN YEARS?

29. WHEN DID YOU LAST HAVE YOUR CHEST X-RAYED? (Year)

30. CHEST X-RAY

a. WHERE DID YOU LAST HAVE YOUR CHEST X-RAYED? (If known) b WHAT WAS THE OUTCOME?

CHEST

DD FORM 2493-1, JAN 2000 PREVIOUS EDITION MAY BE USED.

ASBESTOS EXPOSURE

PART I - INITIAL MEDICAL QUESTIONNAIRE

MEDICAL DATA (Continued) Father Mother

Yes No Don't Know Yes No Don't

Know

31. WERE EITHER OF YOUR NATURAL

PARENTS TOLD THAT THEY HAD A

CHRONIC LUNG CONDITION SUCH AS

a. CHRONIC BRONCHITIS

b. EMPHYSEMA

c. ASTHMA

d. LUNG CANCER

e. OTHER CHEST CONDITIONS

f. IS PARENT CURRENTLY ALIVE?

g. Please specify AGE IF LIVING

AGE AT DEATH

32. COUGH

b. DO YOU USUALLY COUGH AS MUCH AS FOUR TO SIX TIMES

A DAY FOUR OR MORE DAYS OUT OF THE WEEK?

c. DO YOU USUALLY COUGH AT ALL ON GETTING UP OR FIRST

THING IN THE MORNING?

d. DO YOU USUALLY COUGH AT ALL DURING THE REST

OF THE DAY OR AT NIGHT?

IF YES TO ANY OF ABOVE (32.a., b., c., or d.), ANSWER THE

FOLLOWING. IF NO TO ALL, X "N/A" AND SKIP TO ITEM 33.

f. FOR HOW MANY YEARS HAVE YOU HAD THE COUGH?

33. PHLEGM

* a. DO YOU USUALLY BRING UP PHLEGM FROM YOUR CHEST?

(Count phlegm with the first smoke or on first going out of doors.

Exclude phlegm from the nose. Count swallowed phlegm.)

*If No, skip to Item 33.c.

IF YES TO ANY OF ABOVE (33.a., b., c., or d.), ANSWER THE

FOLLOWING. IF NO TO ALL, X "N/A" AND SKIP TO ITEM 34.

e. DO YOU USUALLY BRING UP PHLEGM LIKE THIS ON MOST DAYS

FOR THREE CONSECUTIVE MONTHS OR MORE DURING THE YEAR?

f. FOR HOW MANY YEARS HAVE YOU HAD TROUBLE WITH PHLEGM?

DD FORM 2493-1 (BACK), JAN 2000

Yes No N/A

34. EPISODES OF COUGH AND PHLEGM

a. HAVE YOU HAD PERIODS OR EPISODES OF (increased*) COUGH

AND PHLEGM LASTING FOR THREE WEEKS OR MORE EACH YEAR?

*For persons who usually have cough and/or phlegm

b. FOR HOW LONG HAVE YOU HAD AT LEAST ONE SUCH EPISODE PER YEAR? (Number of years)

35. WHEEZING/WHISTLING

a. DOES YOUR CHEST EVER SOUND WHEEZY OR WHISTLING

(1) When you have a cold

(2) Occasionally apart from colds

(3) Most days or nights

b. IF YES TO 35.a.(1), (2) or (3), FOR HOW MANY YEARS HAS THIS BEEN PRESENT (Number of years)

36. WHEEZING/SHORTNESS

a. HAVE YOU EVER HAD AN ATTACK OF WHEEZING THAT HAS

MADE YOU FEEL SHORT OF BREATH?

b. IF YES, HOW OLD WERE YOU WHEN YOU HAD YOUR FIRST SUCH ATTACK? (Number of years)

c. HAVE YOU HAD TWO OR MORE SUCH EPISODES?

d. HAVE YOU EVER REQUIRED MEDICINE OR TREATMENT FOR THE(SE)

ATTACKS?

37. IF DISABLED FROM WALKING BY ANY CONDITION OTHER THAN HEART

OR LUNG DISEASE, PLEASE DESCRIBE NATURE OF CONDITION(S) AND

PROCEED TO QUESTION 39.a.

b. DO YOU USUALLY BRING UP PHLEGM LIKE THIS AS

TWICE A DAY FOUR OR MORE DAYS OUT OF THE WEEK?

c. DO YOU USUALLY BRING UP PHLEGM AT ALL ON

GETTING UP OR THING IN THE MORNING?

d. DO YOU USUALLY BRING UP PHLEGM AT ALL DURING

THE REST OF THE DAY OR AT NIGHT?

a. DO YOU USUALLY HAVE A COUGH? (Count a cough with first smoke or on first going out of doors.

*If No, skip to question 32.c.

e. DO YOU USUALLY COUGH LIKE THIS ON MOST DAYS

THREE CONSECUTIVE MONTHS OR MORE DURING THE YEAR?

38. BREATHLESSNESS

a. ARE YOU TROUBLED BY SHORTNESS OF BREATH WHEN HURRYING

ON THE LEVEL OR WALKING UP A SLIGHT

b. IF YES, DO YOU HAVE TO WALK SLOWER THAN PEOPLE OF YOUR

AGE ON THE LEVEL BECAUSE OF BREATHLESSNESS?

c. DO YOU EVER HAVE TO STOP FOR BREATH WHEN WALKING AT

YOUR OWN PACE ON THE LEVEL?

d. DO YOU EVER HAVE TO STOP FOR BREATH AFTER WALKING ABOUT 100 YARDS (or after a few minutes) ON THE LEVEL?

e. ARE YOU TOO BREATHLESS TO LEAVE THE HOUSE OR BREATH-

LESS ON DRESSING OR CLIMBING ONE FLIGHT OF STAIRS?

39. CIGARETTE SMOKING

a. HAVE YOU EVER SMOKED CIGARETTES? *No means less than 20 packs of cigarettes or 12 oz. of tobacco in a lifetime or less than 1 cigarette a day for 1 year.

b. IF YES, DO YOU NOW SMOKE CIGARETTES? (As of one month ago)?

c. HOW OLD WERE YOU WHEN YOU FIRST STARTED REGULAR CIGARETTE SMOKING? (Number of years)

d. IF YOU HAVE STOPPED SMOKING CIGARETTES COMPLETELY, HOW OLD WERE YOU WHEN YOU STOPPED?

(List age in (1) or X (2))

(1) Age in years (2) Still smoking

e. HOW MANY CIGARETTES DO YOU SMOKE PER DAY NOW?

f. ON THE AVERAGE OF THE ENTIRE TIME YOU SMOKED, HOW MANY CIGARETTES DID YOU SMOKE PER DAY?

g. DO OR DID YOU INHALE CIGARETTE SMOKE (X one)

(1) Not at all (2) Slightly (3) Moderately (4) Deeply

40. PIPE SMOKING

a. HAVE YOU EVER SMOKED A PIPE REGULARLY?

*Yes means more than 12 oz. of tobacco in a lifetime.

b. HOW OLD WERE YOU WHEN YOU FIRST STARTED PIPE SMOKING?

(Number of years)

c. IF YOU HAVE STOPPED SMOKING A PIPE COMPLETELY, HOW OLD

WERE YOU WHEN YOU STOPPED? (List age in (1) or X (2))

(1) Age in years (2) Still smoking

d. ON THE AVERAGE OF THE ENTIRE TIME YOU SMOKED, HOW

MUCH PIPE TOBACCO DID YOU SMOKE PER WEEK?

(Oz. per week - a standard pouch of tobacco contains 1 1-1/2 oz.)

e. HOW MUCH PIPE TOBACCO DO YOU SMOKE PER WEEK NOW?

f. DO OR DID YOU INHALE PIPE SMOKE (X one)

(1) Not at all (2) Slightly (3) Moderately (4) Deeply

41. CIGAR SMOKING

a. HAVE YOU EVER SMOKED CIGARS REGULARLY?

*Yes means more than 1 cigar a week for a year.

b. HOW OLD WERE YOU WHEN YOU FIRST STARTED REGULAR CIGAR

SMOKING? (Number of years)

c. IF YOU HAVE STOPPED SMOKING CIGARS COMPLETELY, HOW OLD

WERE YOU WHEN YOU STOPPED? (List age in (1) or X (2))

(1) Age in years (2) Still smoking

d. ON THE AVERAGE OF THE ENTIRE TIME YOU SMOKED, HOW MANY

CIGARS DID YOU SMOKE PER WEEK?

e. HOW MANY CIGARS DO YOU SMOKE PER WEEK NOW?

f. DO OR DID YOU INHALE CIGAR SMOKE (X one)

(1) Not at all (2) Slightly (3) Moderately (4) Deeply

43. SIGNATURE 44. DATE SIGNED

(YYYYMMDD)

CAUSE OF DEATH Father: Mother:

N/A N/A

OF BREATH

MUCH AS

FIRST

Exclude clearing of throat.)

FOR

HILL?

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