PERIODIC ASBESTOS MEDICAL QUESTIONNAIRE
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- Terence Nash
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1 Date: / / PERIODIC ASBESTOS MEDICAL QUESTIONNAIRE NAME: SS#: - - COMPANY: 1. OCCUPATIONAL HISTORY A. Have you ever worked full time (30 hours per week or more) for 6 months or more? IF YES, TO 1B: B. Have you ever worked for a year or more in any dusty job? 3. Does not apply Specific job/industry: Total years worked Was dust exposure: 1. Mild 2. Moderate 3. Severe C. Have you ever been exposed to gas or chemical fumes in your work? Specific job/industry Total years worked Was exposure: 1. Mild 2. Moderate 3. Severe D. In the past year what was your: 1. Job occupation 2. Position/job title RECENT MEDICAL HISTORY A. Do you consider yourself to be in good health? If NO, state reason 1661 St. Anthony Avenue - 2nd Floor - St. Paul, MN Baltimore Street - Suite Blaine, MN Corporate Center Curve, Suite 200, Eagan, MN Page 1
2 1. In the past, have you developed: 1. Epilepsy (or fits, seizures, convulsions)? 2. Rheumatoid fever? 3. Kidney disease? 4. Bladder disease? 5. Diabetes? 6. Jaundice? 7. Cancer? CHEST COLDS AND CHEST ILLNESSES A. If you get a cold, does it usually go to your chest? (Usually means more than 1/2 the time) B. During the past year, have you had any chest illnesses that have kept you off work, indoors, at home, or in bed? 3. Don t get colds If YES, to C C. Did you produce phlegm with any of these chest illnesses? D. In the last year, how many such illnesses with (increased) phlegm did you have which lasted a week or more? 3. Does not apply Number of illnesses RESPIRATORY SYSTEM In the past have you had: 1. Asthma: Comments on positive answer: 2. Bronchitis: Comments on positive answer: 3. Hay fever: Comments on positive answer: 4. Pneumonia: Comments on positive answer: 5. Tuberculosis: Comments on positive answer: Page 2
3 6. Chest Surgery: Comments on positive answer: 7. Other lung problems: Comments on positive answer: 8. Heart disease: Comments on positive answer: 9. Frequent colds: Comments on positive answer: 10. Chronic Cough: Comments on positive answer: 11. Shortness of breath with walking/climbing one flight of stairs 1. Yes 2. No Comments on positive answer: DO YOU: 1. Wheeze: Comments on positive answer: 2. Cough up phlegm: Comments on positive answer: 3. Smoke Cigarettes: Comments on positive answer: Date Employee Signature Page 3
4 FOR OFFICE USE ONLY Name of Employee Company Height Weight Blood Pressure Pulse min. Post exercise pulse min. Smoking: Yes No # of Years Chest x-ray within normal limits: Yes No N/A Spirometry results within normal limits: Yes No N/A HEENT Cardiopulmonary: N Ab N Ab outer ear ( ) ( ) percussion ( ) ( ) ear canal ( ) ( ) auscultation ( ) ( ) TM s ( ) ( ) carotid pulses ( ) ( ) nasal mucosa ( ) ( ) heart sounds ( ) ( ) lips ( ) ( ) radial pulses ( ) ( ) tongue ( ) ( ) extremities ( ) ( ) oropharynx ( ) ( ) neck ( ) ( ) trachea ( ) ( ) Page 4
5 Name of Employee Social Security # - - Company Hazmat- Asbestos PHYSICIAN S EXAMINATION AND FINDINGS (To be completed by Physician) I have examined the individual named above and find: (circle one) 1. No physical or medical reason to prohibit this employee from participation in a program which may require the use of respirators. 2. Physical or medical reasons require the following restrictions on participation in a program which may require the use of respirators. 3. No respirator use is permitted for this individual at this time. The employee has been informed by me (the undersigned physician) of the results of the medical examination, increased risk of lung cancer attributable to the combined effect of smoking and asbestos exposure. Yes No N/A Physician Signature Physician Name (Please type or print) Address Phone Number (651) Date / / Provider must complete pages 5 and 6. Send both to employer Page 5
6 Integrated, Comprehensive Occupational Health Services A SBESTOS SUMMARY REPORT Patient Name: The results of my examination HAVE NOT ( ) HAVE ( ) detected a medical condition which would place the employee at an increased risk of material health impairment from exposure to asbestos; and In accordance with OSHA requirements, I have informed the above named individual of the results of his/her medical examination and of any medical condition that may result from his/her exposure to asbestos. Physicians Signature Date Provider must complete pages 5 and 6. Send both to employer Page 6
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Name DOB Sex Age Date MR# PLACE CHARGE TICKET LABEL IN THE DASHED SPACE OR COMPLETE THE ABOVE: PLEASE ANSWER EACH QUESTION AS CORRECTLY AS YOU CAN BY PLACING AN "X" IN APPROPRIATE BOX What is the reason
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