Translate- Part Number:1910
- Part Number Title:Occupational Safety and Health Standards
- Subpart:1910 Subpart Z
- Subpart Title:Toxic and Hazardous Substances
- Standard Number:
- Title:Nonmandatory medical disease questionnaire
- GPO Source:
A. Identification
Plant Name____________________________________________________________ Date__________________________________________________________________ Employee Name_________________________________________________________ S.S. #________________________________________________________________ Job Title_____________________________________________________________ Birthdate:____________________________________________________________ Age:__________________________________________________________________ Sex:__________________________________________________________________ Height:_______________________________________________________________ Weight:_______________________________________________________________ B. Medical History 1. Have you ever been in the hospital as a patient? Yes__ No__ If yes, what kind of problem were you having?___________________________ ________________________________________________________________________ 2. Have you ever had any kind of operation? Yes__ No__ If yes, what kind?______________________________________________________ ________________________________________________________________________ 3. Do you take any kind of medicine regularly? Yes__ No__ If yes, what kind?______________________________________________________ ________________________________________________________________________ 4. Are you allergic to any drugs, foods, or chemicals? Yes__ No__ If yes, what kind of allergy is it?_____________________________________ ________________________________________________________________________ What causes the allergy?________________________________________________ ________________________________________________________________________ 5. Have you ever been told that you have asthma, hayfever, or sinusitis? Yes__ No__ 6. Have you ever been told that you have emphysema, bronchitis, or any other respiratory problems? Yes__ No__ 7. Have you ever been told you had hepatitis? Yes__ No__ 8. Have you ever been told that you had cirrhosis? Yes__ No__ 9. Have you ever been told that you had cancer? Yes__ No__ 10. Have you ever had arthritis or joint pain? Yes__ No__ 11. Have you ever been told that you had high blood pressure? Yes__ No__ 12. Have you ever had a heart attack or heart trouble? Yes__ No__ B-1. Medical History Update 1. Have you been in the hospital as a patient any time within the past year? Yes__ No__ If so, for what condition?______________________________________________ ________________________________________________________________________ 2. Have you been under the care of a physician during the past year? Yes__ No__ If so, for what condition?______________________________________________ ________________________________________________________________________ 3. Is there any change in your breathing since last year? Yes__ No__ Better?_________________________________________________________________ Worse?__________________________________________________________________ No change?______________________________________________________________ If change, do you know why?_____________________________________________ ________________________________________________________________________ 4. Is your general health different this year from last year? Yes__ No__ If different, in what way?______________________________________________ ________________________________________________________________________ 5. Have you in the past year or are you now taking any medication on a regular basis? Yes__ No__ Name Rx_________________________________________________________________ Condition being treated ________________________________________________ C. Occupational History 1. How long have you worked for your present employer? ________________________________________________________________________ 2. What jobs have you held with this employer? Include job title and length of time in each job. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3. In each of these jobs, how many hours a day were you exposed to chemicals? ________________________________________________________________________ 4. What chemicals have you worked with most of the time? ________________________________________________________________________ 5. Have you ever noticed any type of skin rash you feel was related to your work? Yes__ No__ 6. Have you ever noticed that any kind of chemical makes you cough? Yes__ No__ Wheeze? Yes__ No__ Become short of breath or cause your chest to become tight? Yes__ No__ 7. Are you exposed to any dust or chemicals at home? Yes__ No__ If yes, explain:________________________________________________________ ________________________________________________________________________ 8. In other jobs, have you ever had exposure to: Wood dust? Yes__ No__ Nickel of chromium? Yes__ No__ Silica (foundry, sand blasting)? Yes__ No__ Arsenic or asbestos? Yes__ No__ Organic solvents? Yes__ No__ Urethane foams? Yes__ No__ C-1. Occupational History Update 1. Are you working on the same job this year as you were last year? Yes__ No__ If not, how has your job changed?_______________________________________ ________________________________________________________________________ 2. What chemicals are you exposed to on your job? ________________________________________________________________________ 3. How many hours a day are you exposed to chemicals? ________________________________________________________________________ 4. Have you noticed any skin rash within the past year you feel was related to your work? Yes__ No__ If so, explain circumstances:___________________________________________ ________________________________________________________________________ 5. Have you noticed that any chemical makes you cough, be short of breath, or wheeze? Yes__ No__ If so, can you identify it?_____________________________________________ ________________________________________________________________________ D. Miscellaneous 1. Do you smoke? Yes__ No__ If so, how much and for how long?_______________________________________ ________________________________________________________________________ Pipe____________________________________________________________________ Cigars__________________________________________________________________ Cigarettes______________________________________________________________ 2. Do you drink alcohol in any form? Yes__ No__ If so, how much, how long, and how often?_______________________________ ________________________________________________________________________ 3. Do you wear glasses or contact lenses? Yes__ No__ 4. Do you get any physical exercise other than that required to do your job? Yes__ No__ If so, explain:_________________________________________________________ ________________________________________________________________________ 5. Do you have any hobbies or "side jobs" that require you to use chemicals, such as furniture stripping, sand blasting, insulation or manufacture of urethane foam, furniture, etc? Yes__ No__ If so, please describe, giving type of business or hobby, chemicals used and length of exposures. ________________________________________________________________________ E. Symptoms Questionnaire 1. Do you ever have any shortness of breath? Yes__ No__ If yes, do you have to rest after climbing several flights of stairs? Yes__ No__ If yes, if you walk on the level with people your own age, do you walk slower than they do? Yes__ No__ If yes, if you walk slower than a normal pace, do you have to limit the distance that you walk? Yes__ No__ If yes, do you have to stop and rest while bathing or dressing? Yes__ No__ 2. Do you cough as much as three months out of the year? Yes__ No__ If yes, have you had this cough for more than two years? Yes__ No__ If yes, do you ever cough anything up from chest? Yes__ No__ 3. Do you ever have a feeling of smothering, unable to take a deep breath, or tightness in your chest? Yes__ No__ If yes, do you notice that this on any particular day of the week? Yes__ No__ If yes, what day or the week? Yes__ No__ If yes, do you notice that this occurs at any particular place? Yes__ No__ If yes, do you notice that this is worse after you have returned to work after being off for several days? Yes__ No__ 4. Have you ever noticed any wheezing in your chest? Yes__ No__ If yes, is this only with colds or other infections? Yes__ No__ Is this caused by exposure to any kind of dust or other material? Yes__ No__ If yes, what kind?_____________________________________________________ 5. Have you noticed any burning, tearing, or redness of your eyes when you are at work? Yes__ No__ If so, explain circumstances:___________________________________________ ________________________________________________________________________ 6. Have you noticed any sore or burning throat or itchy or burning nose when you are at work? Yes__ No__ If so, explain circumstances:___________________________________________ ________________________________________________________________________ 7. Have you noticed any stuffiness or dryness of your nose? Yes__ No__ 8. Do you ever have swelling of the eyelids or face? Yes__ No__ 9. Have you ever been jaundiced? Yes__ No__ If yes, was this accompanied by any pain? Yes__ No__ 10. Have you ever had a tendency to bruise easily or bleed excessively? Yes__ No__ 11. Do you have frequent headaches that are not relieved by aspirin or tylenol? Yes__ No__ If yes, do they occur at any particular time of the day or week? Yes__ No__ If yes, when do they occur?_____________________________________________ ________________________________________________________________________ 12. Do you have frequent episodes of nervousness or irritability? Yes__ No__ 13. Do you tend to have trouble concentrating or remembering? Yes__ No__ 14. Do you ever feel dizzy, light-headed, excessively drowsy or like you have been drugged? Yes__ No__ 15. Does your vision ever become blurred? Yes__ No__ 16. Do you have numbness or tingling of the hands or feet or other parts of your body? Yes__ No__ 17. Have you ever had chronic weakness or fatigue? Yes__ No__ 18. Have you ever had any swelling of your feet or ankles to the point where you could not wear your shoes? Yes__ No__ 19. Are you bothered by heartburn or indigestion? Yes__ No__ 20. Do you ever have itching, dryness, or peeling and scaling of the hands? Yes__ No__ 21. Do you ever have a burning sensation in the hands, or reddening of the skin? Yes__ No__ 22. Do you ever have cracking or bleeding of the skin on your hands? Yes__ No__ 23. Are you under a physician's care? Yes__ No__ If yes, for what are you being treated?_________________________________ ________________________________________________________________________ 24. Do you have any physical complaints today? Yes__ No__ If yes, explain?________________________________________________________ ________________________________________________________________________ 25. Do you have other health conditions not covered by these questions? Yes__ No__ If yes, explain:________________________________________________________ ________________________________________________________________________