Fillable Respiratory and Asbestos Questionnaire for Occupational Health Services

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Respiratory and Asbestos Questionnaire for Occupational Health Services

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Respiratory and Asbestos Questionnaire
for Occupational Health Services
For a qualified healthcare provider to properly assess the ability of an employee/applicant to wear a
respirator, a medical history must be known. This questionnaire will aid in that regard. Please fill out this
questionnaire as accurately as possible.
Name: Patient ID:
Date of birth: Today’s date:
Employer:
Job title: Length of employment:
Age (to nearest year): Sex: Male Female
Check t
he type of respirator you will use (you can check more than one category):
N, R, or P disposable respirator (filter-mask, non-cartridge type only)
Other type (for example, half- or full-facepiece type, powered-air purifying, supplied-air, self-contained
breathing apparatus).
Have you worn a respirator? Yes No
If “yes”, what type(s):
1.
Do you currently smoke tobacco, or have you smoked tobacco in the last month?
Yes
No
2.
Have you ever had any of the following conditions:
a. Seizures (fits)?
b. Diabetes (sugar disease)?
c. Allergic reactions that interfere with your breathing?
d. Claustrophobia (fear of closed-in places)?
e. Trouble smelling odors (except when you had a cold)?
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
3.
Have you ever had any of the following pulmonary or lung problems:
a. Asbestos?
b. Asthma?
c. Chronic bronchitis?
d. Emphysema?
e. Pneumonia?
f. Tuberculosis?
g. Silicosis?
h. Pneumothorax (collapsed lung)?
i. Lung cancer?
j. Broken ribs?
k. Any chest injuries or surgeries?
l. Any other lung problem that you’ve been told about?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
4.
Do you currently have any of the following symptoms of pulmonary or lung disease:
a. Shortness of breath?
b. Shortness of breath when walking fast on level ground or walking up a slight
hill/incline?
c. Shortness of breath when walking with other people at an ordinary pace on level
ground?
d. Have to stop for breath when walking at your own pace on level ground?
e. Shortness of breath when washing or dressing yourself?
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Patient Name: ______________________________ DOB: ___________________ Pt ID: __________________
f. Shortness of breath that interferes with your job?
g. Coughing that produces phlegm (thick sputum)?
h. Coughing that wakes you early in the morning?
i. Coughing that occurs mostly when you are lying down?
j. Coughing up blood within the last month?
k. Wheezing?
l. Wheezing that interferes with your job?
m. Chest pain when you breathe deeply?
n. Any other symptoms that you think may be related to lung problems?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
5.
Have you ever had any of the following cardiovascular or heart problems?
a. Heart attack?
b. Stroke?
c. Angina?
d. Heart Failure?
e. Swelling in your legs or feet (not caused by walking)?
f. Heart arrhythmia (heart beating irregularly)?
g. High blood pressure?
h. Any other heart problems you have been told about?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
6.
Have you ever had any of the following cardiovascular or heart problems:
a. Frequent pain or tightness in your chest?
b. Pain or tightness in your chest during physical activity?
c. Pain or tightness in your chest that interferes with your job?
d. In the past two years, have you noticed your heart skipping or missing a beat?
e. Heartburn or indigestion that is not related to eating?
f. Any gastrointestinal disease?
g. Any other symptoms that you think may be related to heart or circulation
problems?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
7.
Do you currently take medications for any to the following problems:
a. Breathing or lung problems?
b. Heart problems?
c. Blood pressure?
d. Seizures (fits)?
Yes
Yes
Yes
Yes
No
No
No
No
8.
If you have ever worn a respirator, has it caused any of the following problems:
a. Eye irritation?
b. Skin allergies or rashes?
c. Anxiety that occurs only when you use the respirator?
d. Unusual weakness or fatigue?
e. Any other problem that interferes with your use of a respirator?
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Every employee and/or applicant who has been selected to use either a full-facepiece respirator or a
self-contained breathing apparatus (SCBA) must answer the following questions. For employees who have
been selected to use other types of respirators, answering these questions is voluntary.
9.
Have you ever lost vision in either eye (temporarily or permanently)?
Yes
No
10.
Do you currently have any of the following vision problems:
a. Wear contact lenses?
b. Wear glasses?
c. Color blind?
d. Any other eye or vision problem?
Yes
Yes
Yes
Yes
No
No
No
No
1103106 rev0316
Patient Name: ______________________________ DOB: ___________________ Pt ID: __________________
11.
Have you ever had an injury to your ears, including a broken ear drum?
Yes
No
12.
Do you currently have any of the following hearing problems:
a. Difficulty hearing?
b. Wearing a hearing aid?
c. Any other hearing or ear problem?
Yes
Yes
Yes
No
No
No
13.
Have you ever had a back injury?
Yes
No
14.
Do you currently have any of the following musculoskeletal problems:
a. Weakness in any of your arms, hands, legs, or feet?
b. Back pain?
c. Difficulty fully moving your arms and legs?
d. Pain or stiffness when you lean forward or backward at the waist?
e. Difficulty fully moving your head up or down?
f. Difficulty fully moving your head side to side?
g. Difficulty bending at your knees?
h. Difficulty squatting to the ground?
i. Difficulty climbing a flight of stairs or a ladder carrying more than 25 lbs.?
j. Any other muscle or skeletal problem that interferes with using a respirator?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Please explain all
“Yes” responses to questions 1-14:
Question
Number
Explanation
1103106 rev0316
Patient Name: ______________________________ DOB: ___________________ Pt ID: __________________
www.osha-slc.gov
• Subpart:
Z
• Subpart Title:
Toxic and Hazardous Substances
• Standard Number:
1915.1001 App D
• Title:
Medical Questionnaires; Mandatory
This m
andatory appendix contains the medical questionnaires that must be administered to all employees
who are exposed to asbestos, tremolite, anthophyllite, actinolite, or a combination of these minerals
above the permissible exposure limit (0.1 f/cc), and who will therefore be included in their employer's
medical surveillance program. Part 1 of the appendix contains the Initial Medical Questionnaire, which
must be obtained for all new hires who will be covered by the medical surveillance requirements. Part 2
includes the abbreviated Periodical Medical Questionnaire, which must be administered to all employees
who are provided periodic medical examinations under the medical surveillance provisions of the
standard.
Part 1
INITIAL MEDICAL QUESTIONNAIRE
1. NAME ________________________________________________________________
2. SOCIA
L SECURITY NUMBER # ____________________________________________
3. CLOCK N
UMBER ________________________________________________________
4. PRESENT OCCUPATION __________________________________________________
5. PLANT _____
__________________________________________________________
6. ADDRE
SS _____________________________________________________________
7. _____________________________________________________________________
(Zip Code)
8. TELEPH
ONE NUMBER ____________________________________________________
9. INTERVI
EWER _________________________________________________________
10. DATE ________________________________________________________________
11. Date of B
irth _______________________________________________________
Month Day Year
12. Place
of Birth ______________________________________________________
13. Sex 1. Mal
e ___
2. Female ___
14. What is
your marital status? 1. Single ___ 4. Separated/
2. Married ___ Divorced ___
3. Widowed ___
1103106 rev0316
Patient Name: ______________________________ DOB: ___________________ Pt ID: __________________
15. Race 1. White ___ 4. Hispanic ___
2. Blac
k ___ 5. Indian ___
3. Asi
an ___ 6. Other ___
16. What is the highest grade completed in school? _____________________
(For example 12 years is completion of high school)
OCCUPATI
ONAL HISTORY
17A. Hav
e you ever worked full time (30 hours 1. Yes ___ 2. No ___
per week or more) for 6 months or more?
IF YE
S TO 17A:
B. Have
you ever worked for a year or more in 1. Yes ___ 2. No ___
any dusty job? 3. Does Not Apply ___
Specif
y job/industry _______________ Total Years Worked __________
Was dust
exposure: 1. Mild ____ 2. Moderate ____ 3. Severe ____
C. Hav
e you ever been exposed to gas or 1. Yes ___ 2. No ___
chemical fumes in your work?
Specify job/industry ______________________ Total Years Worked ___
Was expos
ure : 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 occup
ation ________________________________________________
2. Number of
years employed in this occupation ___________________
3. Positi
on/job title ____________________________________________
4. Busi
ness, field or industry ___________________________________
(Record on lines the years in which you have worked in any of these industries, e.g. 1960-1969)
Have yo
u ever worked: YES NO
E. In a mine? ......................... _____ _____
F. In a q
uarry? ....................... _____ _____
G. In a f
oundry? ...................... _____ _____
H. In a pottery? ...................... _____ _____
I. In a cott
on, flax or hemp mill? .... _____ _____
J. With
asbestos? ..................... _____ _____
1103106 rev0316
Patient Name: ______________________________ DOB: ___________________ Pt ID: __________________
18. PAST MEDICAL HISTORY
YES NO
A. Do y
ou consider yourself to be in good health? _____ _____
If "NO" state reason __________________________________________
B. Have
you any defect of vision? ............... _____ _____
If "Y
ES" state nature of defect _______________________________
C. Have you any hearing defect? ................. _____ _____
If "Y
ES" state nature of defect _______________________________
D. Are
you suffering from or have you ever suffered from:
YES NO
a. Epilepsy (or fits, seizures, convulsions)? _____ _____
b. Rheum
atic fever? _____ _____
c. Ki
dney disease? _____ _____
d. Bladder disease? _____ _____
e. Dia
betes? _____ _____
f. Jaund
ice? _____ _____
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. Duri
ng 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 yo
u 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. No ___
3. Does Not Apply ___
C. At what age was your first attack? Age in Years ___
Does Not Apply ___
1103106 rev0316
Patient Name: ______________________________ DOB: ___________________ Pt ID: __________________
2A. Pneumonia (include bronchopneumonia)? 1. Yes ___ 2. No ___
IF YE
S 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. H
ay 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. A
t what age did it start? Age in Years ___
Does Not Apply ___
23A. Hav
e you ever had chronic bronchitis? 1. Yes ___ 2. No ___
IF YE
S TO 23A:
B. Do you still have it? 1. Yes ___ 2. No ___
3. Does Not Apply ___
C. W
as 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. Hav
e 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. W
as 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. Hav
e 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. W
as 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. An
y other chest illness? 1. Yes ___ 2. No ___
If yes, please specify ___________________________________________
1103106 rev0316
Patient Name: ______________________________ DOB: ___________________ Pt ID: __________________
B. Any chest operations? 1. Yes ___ 2. No ___
If y
es, 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 YE
S 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 YE
S 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 H
ISTORY
31. Were eit
her 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. Chron
ic Bronchitis? ___ ___ ___ ___ ___ ___
B. Emphysema? ___ ___ ___ ___ ___ ___
C. Asthma? ___ _
__ ___ ___ ___ ___
D. Lung cancer
? ___ ___ ___ ___ ___ ___
E. Other chest conditions? ___ ___ ___ ___ ___ ___
F. Is par
ent currently alive? ___ ___ ___ ___ ___ ___
G. Pleas
e Specify ___ Age if Living ___ Age if Living
___ Age at Death ___ Age at Death
___ Don't K
now ___ Don't Know
1103106 rev0316
Patient Name: ______________________________ DOB: ___________________ Pt ID: __________________
H. Please specify cause of death
____________________________________ __________________________
COUGH
32A. Do y
ou 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. No ___
C. Do y
ou usually cough at all on getting up or first thing in the
morning?
1. Yes ___ 2. No ___
D. Do y
ou usually cough at all during the rest of the day or at night?
1. Yes ___ 2. No ___
IF YE
S 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 y
ou 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 ho
w many years have you had the cough? Number of years ___
Does not apply ___
33A. Do y
ou 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 y
ou 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 y
ou usually bring up phlegm at all on getting up or first thing
in the morning?
1. Yes ___ 2. No ___
D. Do y
ou usually bring up phlegm at all on during the rest of the day
or at night?
1. Yes ___ 2. No ___
IF YES TO ANY OF THE ABOVE (33A, B, C, OR D), ANSWER THE FOLLOWING:
IF NO T
O ALL, CHECK "DOES NOT APPLY" AND SKIP TO 34A
E. Do y
ou 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 ___
1103106 rev0316
Patient Name: ______________________________ DOB: ___________________ Pt ID: __________________
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 YE
S TO 34A
B. For how long have you had at least 1 such episode per year?
Number of years ___
Does not apply ___
WHEEZIN
G
35A. Does
your chest ever sound wheezy or whistling
1. When you have a cold? 1. Yes ___ 2. No ___
2. Occas
ionally apart from colds? 1. Yes ___ 2. No ___
3. Most
days or nights? 1. Yes ___ 2. No ___
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. Hav
e 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. Hav
e 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 ___
BREATHL
ESSNESS
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?
1. Yes ___ 2. No ___
1103106 rev0316
Patient Name: ______________________________ DOB: ___________________ Pt ID: __________________
IF YES TO 38A
B. Do y
ou 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 y
ou 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 y
ou ever have to stop for breath after walking about 100 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. Hav
e 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 y
ou 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 th
e 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 ___
1103106 rev0316
Patient Name: ______________________________ DOB: ___________________ Pt ID: __________________
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. H
ow 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 t
he 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. Ho
w 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 PERSO
NS WHO HAVE EVER SMOKED A PIPE
B. 1. H
ow old were you when you started Age ___
smoking cigars regularly?
2. If yo
u have stopped smoking cigars Age stopped ___
completely, how old were you when Check if still smoking cigars ___
you stopped. Does not apply ___
C. On th
e 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 d
id you inhale the cigar smoke? 1. Never smoked ___
2. Not at all ___
3. Slightly ___
4. Moderately ___
5. Deeply ___
Signature ____________________________ Date __________________________
1103106 rev0316
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Respiratory and Asbestos Questionnaire for Occupational Health Services

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Completed 10 November 2021

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