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WAC 296-62-07548

Appendix D—Nonmandatory medical disease questionnaire.

(1) Identification.
(a)
Plant name:
(b)
Date:
(c)
Employee name:
(d)
Social Security number:
(e)
Job title:
(f)
Birthdate:
(g)
Age:
(h)
Sex:
(i)
Height:
(j)
Weight:
(2)
Medical history.
(a)
Have you ever been in the hospital as a patient?
Yes □   No □
If yes, what kind of problem were you having?
(b)
Have you ever had any kind of operation?
Yes □   No □
If yes, what kind?
(c)
Do you take any kind of medicine regularly?
Yes □   No □
If yes, what kind?
(d)
Are you allergic to any drugs, foods, or
chemicals?
Yes □   No □
If yes, what kind of allergy is it?
 
What causes the allergy?
(e)
Have you ever been told that you have asthma,
hayfever, or sinusitis?
Yes □   No □
(f)
Have you ever been told that you have
emphysema, bronchitis, or any other
respiratory problems?
Yes □   No □
(g)
Have you ever been told you had hepatitis?
Yes □   No □
(h)
Have you ever been told that you have cirrhosis?
Yes □   No □
(i)
Have you ever been told that you had cancer?
Yes □   No □
(j)
Have you ever had arthritis or joint pain?
Yes □   No □
(k)
Have you ever been told that you had high blood
pressure?
Yes □   No □
(l)
Have you ever had a heart attack or heart trouble?
Yes □   No □
(3)
Medical history update.
(a)
Have you been in the hospital as a patient any
time within the past year?
Yes □   No □
If so, for what condition?
(b)
Have you been under the care of a physician
during the past year?
Yes □   No □
If so, for what condition?
(c)
Is there any change in your breathing since last
year?
Yes □   No □
(i) Better?
(ii) Worse?
(iii) No change?
If change, do you know why?
(d)
Is your general health different this year from last
year?
Yes □   No □
If different, in what way?
(e)
Have you in the past year or are you now taking
any medication on a regular basis?
Yes □   No □
(i) Name Rx
(ii) Condition being treated
(4)
Occupational history.
(a)
How long have you worked for your present
employer?
(b)
What jobs have you held with this employer?
Include job title and length of time in each
job.
(c)
In each of these jobs, how many hours a day were
you exposed to chemicals?
(d)
What chemicals have you worked with most of
the time?
(e)
Have you ever noticed any type of skin rash you
feel was related to your work?
Yes □   No □
(f)
Have you ever noticed that any kind of chemical
makes you cough?
Yes □   No □
(i) Wheeze:
Yes □   No □
(ii) Become short of breath or cause your chest
to become tight?
Yes □   No □
(g)
Are you exposed to any dust or chemicals at
home?
Yes □   No □
If yes, explain:
(h)
In other jobs, have you ever had exposure to:
(i) Wood dust?
Yes □   No □
(ii) Nickel or chromium?
Yes □   No □
(iii) Silica (foundry, sand blasting)?
Yes □   No □
(iv) Arsenic or asbestos?
Yes □   No □
(v) Organic solvents?
Yes □   No □
(vi) Urethane foams?
Yes □   No □
(5)
Occupational history update.
(a)
Are you working on the same job this year as you
were last year?
Yes □   No □
If not, how has your job changed?
(b)
What chemicals are you exposed to on your job?
(c)
How many hours a day are you exposed to
chemicals?
(d)
Have you noticed any skin rash within the past
year you feel was related to your work?
Yes □   No □
If so, explain circumstances:
(e)
Have you noticed that any chemical makes you
cough, be short of breath, or wheeze?
Yes □   No □
If so, can you identify it?
(6)
Miscellaneous.
(a)
Do you smoke?
Yes □   No □
If so, how much and for how long?
(i) Pipe
(ii) Cigars
(iii) Cigarettes
(b)
Do you drink alcohol in any form?
Yes □   No □
If so, how much, how long, and how often?
(c)
Do you wear glasses or contact lenses?
Yes □   No □
(d)
Do you get any physical exercise other than that
required to do your job?
Yes □   No □
If so, explain:
(e)
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.
(7)
Symptoms questionnaire.
(a)
Do you ever have any shortness of breath?
Yes □   No □
(i) If yes, do you have to rest after climbing
several flights of stairs?
Yes □   No □
(ii) If yes, if you walk on the level with people
your own age, do you walk slower than
they do?
Yes □   No □
(iii) If yes, if you walk slower than a normal
pace, do you have to limit the distance
that you walk?
Yes □   No □
(iv) If yes, do you have to stop and rest while
bathing or dressing?
Yes □   No □
(b)
Do you cough as much as three months out of
the year?
Yes □   No □
(i) If yes, have you had this cough for more
than two years?
Yes □   No □
(ii) If yes, do you ever cough anything up
from the chest?
Yes □   No □
(c)
Do you ever have a feeling of smothering, unable
to take a deep breath, or tightness in your
chest?
Yes □   No □
(i) If yes, do you notice that this occurs on any
particular day of the week?
Yes □   No □
(ii) If yes, what day of the week?
(iii) If yes, do you notice that this occurs at any
particular place?
Yes □   No □
(iv) If yes, do you notice that this is worse after
you have returned to work after being off
for several days?
Yes □   No □
(d)
Have you ever noticed any wheezing in your
chest?
Yes □   No □
(i) If yes, is this only with colds or other
infections?
Yes □   No □
(ii) Is this caused by exposure to any kind of
dust or other material?
Yes □   No □
(iii) If yes, what kind?
(e)
Have you noticed any burning, tearing, or redness
of your eyes when you are at work?
Yes □   No □
If so, explain circumstances:
(f)
Have you noticed any sore or burning throat or
itchy or burning nose when you are at work?
Yes □   No □
If so, explain circumstances:
(g)
Have you noticed any stuffiness or dryness of
your nose?
Yes □   No □
(h)
Do you ever have swelling of the eyelids or face?
Yes □   No □
(i)
Have you ever been jaundiced?
Yes □   No □
If yes, was this accompanied by any pain?
Yes □   No □
(j)
Have you ever had a tendency to bruise easily or
bleed excessively?
Yes □   No □
(k)
Do you have frequent headaches that are not
relieved by aspirin or tylenol?
Yes □   No □
(i) If yes, do they occur at any particular time of
the day or week?
Yes □   No □
(ii) If yes, when do they occur?
(l)
Do you have frequent episodes of nervousness or
irritability?
Yes □   No □
(m)
Do you tend to have trouble concentrating or
remembering?
Yes □   No □
(n)
Do you ever feel dizzy, light-headed, excessively
drowsy, or like you have been drugged?
Yes □   No □
(o)
Does your vision ever become blurred?
Yes □   No □
(p)
Do you have numbness or tingling of the hands or
feet or other parts of your body?
Yes □   No □
(q)
Have you ever had chronic weakness or fatigue?
Yes □   No □
(r)
Have you ever had any swelling of your feet or
ankles to the point where you could not wear
your shoes?
Yes □   No □
(s)
Are you bothered by heartburn or indigestion?
Yes □   No □
(t)
Do you ever have itching, dryness, or peeling and
scaling of the hands?
Yes □   No □
(u)
Do you ever have a burning sensation in the
hands, or reddening of the skin?
Yes □   No □
(v)
Do you ever have cracking or bleeding of the skin
on your hands?
Yes □   No □
(w)
Are you under a physician's care?
Yes □   No □
If yes, for what are you being treated?
(x)
Do you have any physical complaints today?
Yes □   No □
If yes, explain:
(y)
Do you have other health conditions not covered
by these questions?
Yes □   No □
If yes, explain:
[Statutory Authority: Chapter 49.17 RCW. WSR 88-21-002 (Order 88-23), § 296-62-07548, filed 10/6/88, effective 11/7/88.]
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