Exhibit_Two_-_MEDICAL_QUESTIONNAIRE_2.pdf

PDF 48 KB Posted Aug 16, 2016

Attached to: Occupational Health Medical Surveillance Physical Exams
Solicitation number: W912J3-16-T-0030
Issued by: Department of the Army New Mexico Army National Guard

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Exhibit Two - MEDICAL QUESTIONNAIRE 2

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Other files

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Amendment_0002_-_Extend_Proposal_Due_Date.pdf	PDF	Aug 26, 2016
Amendment_0001_-_W912J3-16-T-0030_-_Question_and_Answer.pdf	PDF	Aug 16, 2016
Exhibit_One_-_OPNAV_5100-15_(5-90)_Example_Medical_Surveillance_Questionnaire.pdf	PDF	Aug 16, 2016
Exhibit_Four_-_Appendix_C_to_Sec._1910.134_OSHA_Respirator_Medical_Evaluation_Questionnaire.pdf	PDF	Aug 16, 2016
Exhibit_Three_-_OSHA_Info_Sheet_Respirator_Medical_Evaluation_Questionnaire.pdf	PDF	Aug 16, 2016
Attachment__2-Wage_Determination_-_15-2511_(Rev.-1)_Dated_23_Feb._2016.pdf	PDF	Jul 28, 2016
Attachment__1-Wage_Determination_-_05-2361_(Rev-18)_Dated_5_January_2016.pdf	PDF	Jul 28, 2016
Attachment__3-Wage_Determination_-_15-2517_(Rev.-2)_Dated_8_March_2016.pdf	PDF	Jul 28, 2016
Solicitation_W912J3-16-T-0030.pdf	PDF	Jul 28, 2016

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Part 1

INITIAL MEDICAL QUESTIONNAIRE

1. NAME

2. SOCIAL SECURITY NUMBER #

3. CLOCK NUMBER

4. PRESENT OCCUPATION

5. PLANT

6. ADDRESS

(Zip Code)

8. TELEPHONE NUMBER

9. INTERVIEWER

10. DATE

11. Date of Birth Month Day Year

12. Place of Birth

13. Sex 1. Male ___

2. Female ___

14. What is your marital status? 1. Single ___ 4.

Separated/

2. Married ___ Divorced ___

3. Widowed ___

15. Race 1. White ___ 4.

Hispanic ___

2. Black ___ 5. Indian

3. Asian ___ 6. Other

16. What is the highest grade completed in school?

(For example 12 years is completion of high school)

OCCUPATIONAL HISTORY

17A. Have you ever worked full time (30 1. Yes ___ 2.

No ___ hours per week or more) for 6 months or more?

IF YES TO 17A:

B. Have you ever worked for a year or 1. Yes ___ 2.

No ___ more in any dusty job? 3. Does Not Apply ___

Specify job/industry ____________ Total Years Worked

Was dust exposure:

1. Mild ____ 2. Moderate ____ 3.

Severe ____

C. Have you ever been exposed to gas or 1. Yes ___ 2.

No ___ chemical fumes in your work?

Specify job/industry _________________ Total Years Worked ___

Was exposure :

1. Mild ____ 2. Moderate ____ 3.

Severe ____

D. What has been your usual occupation or job -- 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 (Record on lines the years in which you have worked in any of these industries, e.g. 1960-1969)

Have you ever worked: YES

E. In a mine? ......................... _____

F. In a quarry? ....................... _____

G. In a foundry? ...................... _____

H. In a pottery? ...................... _____

I. In a cotton, flax or hemp mill? .... _____

J. With asbestos? ..................... _____

18. PAST MEDICAL HISTORY

YES

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:

YES

a. Epilepsy (or fits, seizures, convulsions)? _____

b. Rheumatic fever? _____

c. Kidney disease? _____

d. Bladder disease? _____

e. Diabetes? _____

f. Jaundice? _____

19. CHEST COLDS AND CHEST ILLNESSES

19A. If you get a cold, does it "usually" go to your chest? (Usually means more than 1/2 the time)

1. Yes ___ 2. No ___ 3. Don't get colds ___

20A. During the past 3 years, have you had any chest illnesses that have kept you off work, indoors at home, or in bed?

1. Yes ___ 2. No ___

IF YES TO 20A:

B. Did you produce phlegm with any of these chest illnesses?

1. Yes ___ 2. No ___ 3. Does Not Apply

C. In the last 3 years, how many such illnesses with (increased) phlegm did you have which lasted a week or more?

Number of illnesses ___ No such illnesses

21. Did you have any lung trouble before the age of 16?

1. Yes ___ 2. No ___

22. Have you ever had any of the following?

1A. Attacks of bronchitis? 1. Yes ___ 2.

No ___

IF YES TO 1A:

B. Was it confirmed by a doctor? 1. Yes ___ 2.

3. Does Not Apply ___

C. At what age was your first attack? Age in Years Does Not Apply

2A. Pneumonia (include bronchopneumonia)? 1. Yes ___ 2.

No ___

IF YES TO 2A:

B. Was it confirmed by a doctor? 1. Yes ___ 2.

No ___

3. Does Not Apply ___

C. At what age did you first have it? Age in Years ___ Does Not Apply ___

3A. Hay Fever? 1. Yes ___ 2.

No ___

IF YES TO 3A:

B. Was it confirmed by a doctor? 1. Yes ___ 2.

No ___

3. Does Not Apply ___

C. At what age did it start? Age in Years ___ Does Not Apply ___

23A. Have you ever had chronic bronchitis? 1. Yes ___

2. No ___

IF YES TO 23A:

B. Do you still have it? 1. Yes ___ 2.

No ___

3. Does Not Apply ___

C. Was it confirmed by a doctor? 1. Yes ___ 2.

No ___

3. Does Not Apply ___

D. At what age did it start? Age in Years ___

Does Not Apply ___

24A. Have you ever had emphysema? 1. Yes ___

2. No ___

IF YES TO 24A:

B. Do you still have it? 1. Yes ___ 2.

No ___

3. Does Not Apply ___

C. Was it confirmed by a doctor? 1. Yes ___ 2.

No ___

3. Does Not Apply ___

D. At what age did it start? Age in Years ___ Does Not Apply ___

25A. Have you ever had asthma? 1. Yes ___

2. No ___

IF YES TO 25A:

B. Do you still have it? 1. Yes ___ 2.

No ___

3. Does Not Apply ___

C. Was it confirmed by a doctor? 1. Yes ___ 2.

No ___

3. Does Not Apply ___

D. At what age did it start? Age in Years ___ Does Not Apply ___ E. If you no longer have it, at what age did it stop?

Age stopped Does Not Apply ___

26. Have you ever had:

A. Any other chest illness? 1. Yes ___ 2.

No ___

If yes, please specify

B. Any chest operations? 1. Yes ___ 2.

If yes, please specify

C. Any chest injuries? 1. Yes ___ 2.

No ___

If yes, please specify

27A. Has a doctor ever told you that you had heart trouble?

1. Yes ___ 2.

No ___

IF YES TO 27A:

B. Have you ever had treatment for heart trouble in the past 10 years?

1. Yes ___ 2.

No ___

3. Does Not Apply ___

28A. Has a doctor told you that you had high blood pressure?

1. Yes ___ 2.

No ___

IF YES TO 28A:

B. Have you had any treatment for high blood pressure (hypertension) in the past 10 years?

1. Yes ___ 2.

No ___

3. Does Not Apply ___

29. When did you last have your chest X-rayed?

(Year) ___ ___ ___ ___

30. Where did you last have your chest X-rayed (if known)?

What was the outcome?

FAMILY HISTORY

31. Were either of your natural parents ever told by a doctor that they had a chronic lung condition such as:

FATHER MOTHER

1. Yes 2. No 3. Don't 1. Yes 2. No 3.

Don't know know

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 if Living ___ Age at Death ___ Age at Death ___ Don't Know ___ Don't Know

H. Please specify cause of death

COUGH

32A. Do you usually have a cough? (Count a cough with first smoke or on first going out of doors. Exclude clearing of throat.)

(If no, skip to question 32C.)

1. Yes ___ 2.

No ___

B. Do you usually cough as much as 4 to 6 times a day 4 or more days out of the week?

1. Yes ___ 2.

C. Do you usually cough at all on getting up or first thing in the morning?

1. Yes ___ 2.

No ___

D. Do you usually cough at all during the rest of the day or at night?

1. Yes ___ 2.

No ___

IF YES TO ANY OF ABOVE (32A, B, C, OR D,), ANSWER THE

FOLLOWING.

IF NO TO ALL, CHECK "DOES NOT APPLY" AND SKIP TO NEXT PAGE

E. Do you usually cough like this on most days for 3 consecutive months or more during the year?

1. Yes ___ 2.

No ___

3. Does not apply ___

F. For how many years have you had the cough?

Number of years ___ Does not apply ___

33A. 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 33C)

1. Yes ___ 2.

No ___

B. Do you usually bring up phlegm like this as much as twice a day 4 or more days out of the week?

1. Yes ___ 2.

No ___

C. Do you usually bring up phlegm at all on getting up or first thing in the morning?

1. Yes ___ 2.

No ___

D. Do you usually bring up phlegm at all on during the rest of the day or at night?

No ___

IF YES TO ANY OF THE ABOVE (33A, B, C, OR D), ANSWER THE

FOLLOWING:

IF NO TO ALL, CHECK "DOES NOT APPLY" AND SKIP TO 34A

E. Do you bring up phlegm like this on most days for 3 consecutive months or more during the year?

1. Yes ___ 2.

No ___

3. Does not apply ___

F. For how many years have you had trouble with phlegm?

Number of years ___ Does not apply ___

EPISODES OF COUGH AND PHLEGM

34A. Have you had periods or episodes of (increased*) cough and phlegm lasting for 3 weeks or more each year?

* (For persons who usually have cough and/or phlegm)

1. Yes ___ 2.

No ___

IF YES TO 34A

B. For how long have you had at least 1 such episode per year?

Number of years ___ Does not apply ___

WHEEZING

35A. Does your chest ever sound wheezy or whistling

1. When you have a cold? 1. Yes ___ 2.

No ___

2. Occasionally apart from colds? 1. Yes ___ 2.

No ___

3. Most days or nights? 1. Yes ___ 2.

IF YES TO 1, 2, or 3 in 35A

B. For how many years has this been present?

Number of years ___ Does not apply ___

36A. Have you ever had an attack of wheezing that has made you feel short of breath?

1. Yes ___ 2.

No ___

IF YES TO 36A

B. How old were you when you had your first such attack?

Age in years ___ Does not apply ___

C. Have you had 2 or more such episodes?

1. Yes ___ 2.

No ___

3. Does not apply ___

D. Have you ever required medicine or treatment for the(se) attack(s)?

1. Yes ___ 2.

No ___

3. Does not apply ___

BREATHLESSNESS

37. If disabled from walking by any condition other than heart or lung disease, please describe and proceed to question 39A.

Nature of condition(s)

38A. Are you troubled by shortness of breath when hurrying on the level or walking up a slight hill?

IF YES TO 38A

B. Do you have to walk slower than people of your age on the level because of breathlessness?

1. Yes ___ 2.

No ___

3. Does not apply ___

C. Do you ever have to stop for breath when walking at your own pace on the level?

1. Yes ___ 2.

No ___

3. Does not apply ___

D. Do you ever have to stop for breath after walking about yards (or after a few minutes) on the level?

1. Yes ___ 2.

No ___

3. Does not apply ___

E. Are you too breathless to leave the house or breathless on dressing or climbing one flight of stairs?

1. Yes ___ 2.

No ___

3. Does not apply ___

TOBACCO SMOKING

39A. 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.)

1. Yes ___ 2.

No ___

IF YES TO 39A

B. Do you now smoke cigarettes (as of one month ago)

1. Yes ___ 2.

No ___

3. Does not apply ___

C. How old were you when you first started regular cigarette smoking?

Age in years ___ Does not apply ___

D. If you have stopped smoking cigarettes completely, how old were you when you stopped?

Age stopped Check if still smoking ___ Does not apply

E. How many cigarettes do you smoke per day now?

Cigarettes per day Does not apply

F. On the average of the entire time you smoked, how many cigarettes did you smoke per day?

Cigarettes per day Does not apply

G. Do or did you inhale the cigarette smoke?

1. Does not apply

2. Not at all

3. Slightly

4. Moderately

5. Deeply

40A. Have you ever smoked a pipe regularly?

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

1. Yes ___ 2.

No ___

IF YES TO 40A:

FOR PERSONS WHO HAVE EVER SMOKED A PIPE

B. 1. How old were you when you started to smoke a pipe regularly?

Age ___

2. If you have stopped smoking a pipe completely, how old were you when you stopped?

Age stopped Check if still smoking pipe ___ Does not apply

C. On the average over the entire time you smoked a pipe, how much pipe tobacco did you smoke per week?

___ oz.

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

___ Does not apply

D. How much pipe tobacco are you smoking now?

oz. per week Not currently smoking a pipe ___

E. Do you or did you inhale the pipe smoke?

1. Never smoked ___

2. Not at all

3. Slightly

4. Moderately

5. Deeply

41A. Have you ever smoked cigars regularly?

1. Yes ___ 2.

No ___ (Yes means more than 1 cigar a week for a year)

IF YES TO 41A

FOR PERSONS WHO HAVE EVER SMOKED A CIGARS

B. 1. How old were you when you started Age ___ smoking cigars regularly?

2. If you have stopped smoking cigars Age stopped completely, how old were you when Check if still you stopped. smoking cigars

Does not apply

C. On the average over the entire time you Cigars per week ___ smoked cigars, how many cigars did you Does not apply smoke per week?

D. How many cigars are you smoking per week Cigars per week ___ now? Check if not smoking cigars currently

E. Do or did you inhale the cigar smoke? 1. Never smoked

2. Not at all

3. Slightly

4. Moderately

5. Deeply

Signature ____________________________ Date

Part 2

PERIODIC MEDICAL QUESTIONNAIRE

1. NAME

2. SOCIAL SECURITY # ___ ___ ___ ___ ___ ___ ___

3. CLOCK NUMBER ___ ___ ___ ___ ___

4. PRESENT

OCCUPATION_____________________________________________

5. PLANT

6. ADDRESS

(Zip Code)

8. TELEPHONE NUMBER

9. INTERVIEWER

10. DATE ______________________ ___ ___ ___ ___

11. What is your marital status? 1. Single ___ 4.

Separated/.

2. Married ___ Divorced ___

3. Widowed ___

12. OCCUPATIONAL HISTORY

12A. In the past year, did you work 1. Yes ___ 2.

No ___ full time (30 hours per week or more) for 6 months or more?

IF YES TO 12A:

12B. In the past year, did you work 1. Yes ___ 2.

No ___ in a dusty job? 3. Does not Apply ___

12C. Was dust exposure:

1. Mild ___ 2. Moderate ___ 3. Severe

12D. In the past year, were you 1. Yes ___ 2.

No ___ exposed to gas or chemical fumes in your work?

12E. Was exposure: 1. Mild ___ 2. Moderate ___ 3.

Severe ___

12F. In the past year, what was your:

1. Job/occupation?

2. Position/job title?

13. RECENT MEDICAL HISTORY

13A. Do you consider yourself to be in good health? Yes ___ No ___

If NO, state reason

13B. In the past year, have you developed: Yes No Epilepsy? ___ Rheumatic fever? ___ Kidney disease? ___ Bladder disease? ___ Diabetes? ___ Jaundice? ___ Cancer? ___

14. CHEST COLDS AND CHEST ILLNESSES

14A. If you get a cold, does it "usually" go to your chest?

(usually means more than 1/2 the time)

1. Yes ___ 2.

No ___

3. Don't get colds ___

15A. During the past year, have you had any chest illnesses that have kept you 1. Yes ___ 2.

No ___ off work, indoors at home, or in bed? 3. Does Not Apply ___

IF YES TO 15A:

15B. Did you produce phlegm with any 1. Yes ___

2. No ___ of these chest illnesses? 3. Does Not Apply ___

15C. In the past year, how many such Number of illnesses ___ illnesses with (increased) phlegm No such illnesses ___ did you have which lasted a week or more?

16. RESPIRATORY SYSTEM

In the past year have you had:

Yes or No Further Comment on Positive Answers Asthma _____

Bronchitis _____

Hay Fever _____

Other Allergies _____

Yes or No Further Comment on Positive Answers Pneumonia _____

Tuberculosis _____

Chest Surgery _____