DATE: Can you read? (Circle one) Yes No DEMOGRAPHIC/PHYSICAL INFORMATION SOCIAL HISTORY PAST MEDICAL HISTORY

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1 MEDCENTER 100 Instructions: This questionnaire is used to gather information about your health and physical condition, both now and in the past. This information will be used to determine if you can safely perform the duties of your job. This exam is not intended to substitute for the care provided by a personal physician. Please review. DATE: Can you read? (Circle one) Yes No DEMOGRAPHIC/PHYSICAL INFORMATION NAME: SOCIAL SECURITY NUMBER: SEX: MALE FEMALE HOME ADDRESS: BIRTH DATE: AGE: MARITAL STATUS: / / S M D POSITION: COMPANY: HOME PHONE: ( ) WORK PHONE: ( ) EMERGENCY CONTACT PHONE #: ( ) HEIGHT: ft. inches WEIGHT: lbs SOCIAL HISTORY a. Do you now smoke cigarettes? Yes No If yes, how many years have you smoked? b. If you have ever smoked, approximately how many packs per day on average? <1/ More than 3 c. Do you drink alcoholic beverages every day? Yes No If yes, how many drinks, beers or glasses of wine do you drink daily? <1/ More than 8 d. How often do you engage in strenuous exercise for at least 20 minutes at a time? Daily 3 times/wk 1 time/wk Rarely Never e. Do you use any of the following tobacco products? pipe tobacco cigars snuff PAST MEDICAL HISTORY (For Yearly or Exit Exam Indicate Change Since Last Exam) 1. Are you currently being treated for illness or injury? Yes No 2. Have you been treated for chronic illness or injury? Yes No 3. Describe fully any yes responses: 4. Please list HOSPITAL ADMISSIONS: If none, check here: YEAR REASON FOR HOSPITALIZATION LENGTH OF STAY 5. Please list allergies to any medicine, food, clothing, bee stings or other substances: f. When was the last year you received a tetanus immunization booster? 1

2 OCCUPATIONAL HISTORY Beginning with most recent, list all jobs held including military. Check boxes to right for indicated exposures. TYPE OF WORK EMPLOYER DATES FROM (mo/day/yr) TO (mo/day/yr) LEAD ASBESTOS INSECTICIDES/PESTI CIDES ORGANIC SOLVENTS SILICA IRON COAL HEAVY METALS OTHER BERYLLIUM How many days have you worked with hazardous agents since your last employer-provided medical monitoring examination?? Have you ever worked on a HAZMAT team? Yes No Have you ever had an illness caused by your work? Yes No If yes, were you seen by a physician? Please describe, including the exposure(s) and note which job above it corresponds to. Please also describe any hazardous exposure(s) not addressed above: Have you ever had an injury caused by work? Yes No If Yes, were you seen by a physician? Please describe, including treatment and appropriate date: Have you ever been restricted in your job activities for medical reasons? Yes No If Yes, please describe: Have you ever worn a respirator at work? Yes No If Yes, what kind? ½ Mask Full Face SCBA Other Check the type of respirator you will use now: N, R, or P disposable respirator (filter mask, non-cartridge type only) Other type (for example, half or full-face type, powered air purifying, supplied air, scuba) Have you ever experienced difficulty wearing a respirator? Yes No If Yes, please describe: Do you have any hobbies or second jobs/side businesses in which you are exposed to hazardous materials? Yes No If Yes, please describe: 2

3 REVIEW OF SYSTEMS Have you experienced any of the following symptoms recently, or on a continuing basis? Describe any yes responses, by number at the end of this section. # SYMPTOM Y N DATE # SYMPTOM Y N DATE HEART/LUNGS NOSE/THROAT EARS EYES MISCELLANEOUSUS 1 Fever ` 35 Chest Pain/Angina * 2 Chills 36 Wheezing 3 Weight Loss 37 Emphysema 4 Loss of Energy/Fatigue 38 Heart Surgery 5 Cancer or Tumors 39 High Blood Pressure * 6 Heat-Related Illness 40 Heart Murmur 7 Eye Surgery 41 Enlarged Heart 8 Color Blindness 42 Heart Arrhythmia * 9 Double Vision 43 Rheumatic Fever 10 Eye Injury 44 Heart Palpitations 11 Cataract 45 Heart Attack/Heart Failure * 12 Glaucoma HEART/LUNGS, CONTINUED 46 Heart Medication 13 Wear glasses/contacts 47 Varicose Veins 14 Ear Infection 48 Stroke * 15 Ear Surgery 49 Leg Ulcers 16 Loss of Hearing 50 Swelling in Legs, Feet or Ankles 17 Ringing in Ears (Tinnitus) CIRCULATION 51 Leg Pain on Walking 18 Hearing Aid Use 52 Anemia 19 Sinus Trouble * 53 Leukemia/Lymphoma 20 Hay Fever/Allergies * BLOOD 54 Other Blood Diseases 21 Frequent Colds 55 Head Injury 22 Sore Throats HEAD 56 Neck Injury 23 Frequent Hoarseness 57 Diabetes * 24 Mouth/Dental Problems 58 Pituitary Problems 25 Frequent Nose Bleeds ENDOCRIN 59 Thyroid Problems 26 Tuberculosis * 60 Frequent Headaches 27 Chest Surgery/Injury * 61 Epilepsy/Seizures 28 Asthma * 62 Fainting Spells 29 Lung Collapse/Pneumothorax * 63 Loss of consciousness 30 Bronchitis * 64 Dizziness or Vertigo 31 Pneumonia * 65 Frequent Exhaustion 32 Asbestosis/Silicosis * 66 Trouble with Nerves 33 Shortness of Breath * NERVOUS SYSTEM 67 Worry/Depression 34 Chronic Cough * *If patient replies yes to any of these questions, physical exam is required. 3

4 REVIEW OF SYSTEMS, CONTINUED # SYMPTOM Y N DATE # SYMPTOM Y N DATE 68 Back Surgery 94 Kidney Trouble/Stones 69 Slipped or Herniated Disc 95 Bladder Trouble 70 Back Injury or Strain 96 Kidney/Bladder Surgery 71 Back X-Rays 97 Urinary Tract Infections 72 Chiropractic Treatment 98 Blood in Urine KIDNEYS BONES/JOINTS 73 Arthritis/Rheumatism 99 Difficulty Urinating 74 Swollen Joints 100 Rash/Dermatitis 75 Amputation 101 Bruise Easily 76 Broken Bones (Ribs?) * 102 Psoriasis 77 Dislocations 103 Wart/Mole Change SKIN 78 Painful Feet 104 Eczema 79 Carpal Tunnel Syndrome 105 Acne 80 Wrist Problems 106 Venereal Disease 81 Knee Problems 107 Infertility 82 Ulcers 108 Difficulty conceiving 83 Colitis 109 Children with Birth Defects 84 Diarrhea (frequent) REPRODUCTIVE 110 Repeated Miscarriage GASTROINTESTINAL 85 Stomach Problems 111 Painful Menstruation 86 Persistent Nausea/Vomiting 112 Irregular Periods 87 Blood in Stool 113 Hysterectomy 88 Rectal Bleeding/Hemorrhoids 114 Are You Pregnant 89 Abnormal Liver Function Tests 115 Date of last Pelvic/Pap Smear 90 Hepatitis 116 Date of last Mammogram FEMALES 91 Cirrhosis 117 Impotency 92 Yellow Jaundice 118 Prostate Problems 93 Gallbladder Trouble/Stones * If patient replies yes to any of these questions, physical exam is required Have you ever had claustrophobia? Yes No 120. Have you ever had trouble smelling odors Yes No 121. Do you currently have any of the following symptoms? a. Shortness of breath Yes No b. Shortness of breath when walking fast on level ground or walking up a slight hill or incline? Yes No c. Shortness of breath when walking with other people at an ordinary pace? Yes No d. Have to stop for breath when walking at your own pace on level ground? Yes No e. Shortness of breath when washing or dressing yourself? Yes No f. Shortness of breath that interferes with your job? Yes No g. Coughing that produces phlegm (thick sputum)? Yes No h. Coughing that wakes you early in the morning? Yes No i. Coughing that occurs mostly when you are lying down? Yes No j. Coughing up blood in the last month? Yes No k. Wheezing that interferes with your job? Yes No l. Chest pain when you breathe deeply? Yes No m. Any other symptoms that you think may be related to lung problems? Yes No 4 MALES

5 122. Have you ever had any of the following cardiovascular or heart symptoms? a. Pain or tightness in your chest during physical activity? Yes No b. Pain or tightness in your chest that interferes with your job? Yes No c. In the last two years, have you noticed your heart skipping or missing a beat? Yes No d. Heartburn or indigestion that is not related to eating? Yes No e. Any other symptoms that you think may be related to heart problems? Yes No 123. If you ve used a respirator, have you ever had any of the following problems? a. Eye irritation? Yes No b. Skin allergies or rashes? Yes No c. Anxiety? Yes No d. General weakness or fatigue? Yes No e. Any other problem that interferes with your use of a respirator? Yes No 124. How often are you expected to use the respirator(s)? (Circle yes or no for all that apply to you.) a. Escape only (no rescue) Yes No b. Emergency rescue only Yes No c. Less than 5 hours per week Yes No d. Less than 2 hours per day Yes No e. 2 4 hours per day Yes No f. Over 4 hours per day Yes No 125. What will you be doing while wearing the respirator? 126. Would you like to talk to the health care professional who will review this questionnaire about your answers to this questionnaire? Yes No Questions 127 through 132 below must be answered by every employee who has been selected to use either a fullfacepiece respirator or a self-containing breathing apparatus (SCBA). For employees who have been selected to use other types of respirators, answering these questions is voluntary Have you ever lost vision in either eye (temporarily or permanently) Yes No 128. Do you currently have any of the following vision problems: a. Wear contact lenses? Yes No b. Wear glasses? Yes No c. Color blind? Yes No d. Any other eye or vision problem? Yes No 129. Have you ever had an injury to your ears, including a broken ear drum? Yes No 130. Do you currently have any of the following hearing problems: a. Difficulty hearing? Yes No b. Wear a hearing aid? Yes No c. Any other hearing or ear problem? Yes No 131. Have you ever had a back injury? Yes No 132. Do you currently have any of the following musculoskeletal problems: a. Weakness in any of your arms, hands, legs or feet? Yes No b. Back pain? Yes No c. Difficulty fully moving your arms and legs Yes No d. Pain or stiffness when you lean forward or backward at the waist? Yes No e. Difficulty fully moving your head up or down? Yes No f. Difficulty fully moving your head side to side? Yes No g. Difficulty bending at your knees? Yes No h. Difficulty squatting to the ground? Yes No i. Climbing a flight of stairs or a ladder carrying more than 25 lbs.? Yes No j. Any other muscle or skeletal problem that interferes with using a respirator? Yes No 5

6 Describe any yes answers fully on the spaces below. Please list the number of the question you are referring to. Are any of the above positive responses work related? Yes No If Yes, please describe: Please list each medication you currently take, the dosage, the frequency with which it is taken, and the reason for taking it: MEDICATION DOSAGE FREQUENCY REASON If patient is taking medication for breathing, heart, blood pressure or seizure, a follow-up exam is necessary. FAMILY HISTORY Father: List Diseases Mother: List Diseases Brothers: List Diseases Sisters: List Diseases Has any member of our immediate family had any of the following? Yes No Yes No Yes No Cancer Diabetes Epilepsy Hypertension Tuberculosis Rheumatism Kidney Disease Heart Disease Anemia/Blood Disorder Employee Signature Date Physician Signature 6 Date