B.06.05 Attachment 5 - Asbestos Exposure, Part II - Periodic Medical Questionnaire.pdf

ASBESTOS EXPOSURE

PART II - PERIODIC 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. MARITAL STATUS (X one)

a. SINGLE

c. WIDOWED

b. MARRIED

d. DIVORCED/SEPARATED

MEDICAL DATA

12. OCCUPATIONAL HISTORY Yes No N/A

a. IN THE PAST YEAR, DID YOU WORK FULL TIME (30 hours per week or more) FOR SIX MONTHS OR MORE?

b. DID YOU WORK AT ANY DUSTY JOB DURING THE PAST YEAR?

*If Yes, complete c.

d. IN THE PAST YEAR, WERE YOU EXPOSED TO GAS OR CHEMICAL FUMES IN YOUR WORK? *If Yes, complete e.

f. IN THE PAST YEAR, WHAT WAS YOUR

(1) Job/Occupation

(2) Position/Job Title

13. MEDICAL HISTORY

Yes No

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

b. IN THE PAST YEAR, HAVE YOU DEVELOPED

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

(2) Rheumatic Fever

(3) Kidney Disease

(4) Bladder Disease

(5) Diabetes

(6) Jaundice

DD FORM 2493-2, JAN 2000 PREVIOUS EDITION MAY BE USED.

14. 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

15. CHEST ILLNESSES

a. DURING THE PAST YEAR, HAVE YOU HAD ANY CHEST 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 YEAR, HOW MANY SUCH ILLNESSES WITH INCREASED PHLEGM DID YOU HAVE WHICH LASTED A WEEK OR MORE? (List number)

c. WAS EXPOSURE (X one) MILD MODERATE SEVERE

e. WAS EXPOSURE (X one) MILD MODERATE SEVERE

16. RESPIRATORY SYSTEM

a. IN THE PAST YEAR, HAVE

YOU HAD

(1) Asthma

(2) Bronchitis

(3) Hay Fever

(4) Other Allergies

(5) Pneumonia

(6) Tuberculosis

(7) Chest Surgery

(8) Other Lung Problems

(9) Heart Disease

Yes Nob. DO YOU HAVE

(1) Frequent Colds

(2) Chronic Cough

(3) Shortness of breath when walking or climbing one flight of stairs

c. DO YOU

(1) Wheeze

(2) Cough up phlegm

(3) Smoke cigarettes (If yes:)

Packs per day

Number of years

18. SIGNATURE 19. DATE SIGNED

(YYYYMMDD)

17. REMARKS (*Use this section to further comment on positive answers)

Yes No N/A