This mandatory 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. Question 1: Name. Question 2: Clock Number. Question 3: Present Occupation. Question 4: Plant. Question 5: Address. Question 6: ZIP Code. Question 7: Telephone Number. Question 8: Interviewer. Question 9: Date. Question 10: Date of Birth.
Question 11: Place of Birth. Question 12: Sex. Question 13: What is your marital status? Question 14: Race. Question 15: What is the highest grade completed in school? Occupational History. Question 16A: Have you ever worked full time (30 hours per week or more) for 6 months or more? If yes to 16A: B: Have you ever worked for a year or more in any dusty job? Specify job/industry. Was dust exposure: C: Have you ever been exposed to gas or chemical fumes in your work? Specify job/industry. Was exposure:
D: What has been your usual occupation or job - the one you have worked at the longest? 1: Job occupation. 2: Number of years employed in this occupation. 3: Position/job title. 4: Business, field or industry. (Record on lines the years in which you have worked in any of these industries, e.g. 1960-1969) Have you ever worked: E. In a mine? F. In a quarry? G. In a foundry? H. In a pottery? I. In a cotton, flax or hemp mill? J. With asbestos? Question 17: Past medical history. A. Do you consider yourself to be in good health? If "NO" state reason. B. Have you any defect of vision? If "YES" state nature of defect. C. Have you any hearing defect? If "YES" state nature of defect
D. Are you suffering from or have you ever suffered from: a. Epilepsy (or fits, seizures, convulsions)? b. Rheumatic fever? c. Kidney disease? d. Bladder disease? e. Diabetes? f. Jaundice? Question 18: Chest colds and chest illnesses. 18A. If you get a cold, does it "usually" go to your chest? (Usually means more than 1/2 the time). 19A. During the past 3 years, have you had any chest illnesses that have kept you off work, indoors at home, or in bed? If yes to 19A: B. Did you produce phlegm with any of those chest illnesses? C. In the last 3 years, how many such illnesses with (increased) phlegm did you have which lasted a week or more? Question 20: Did you have any lung trouble before the age of 16?
Question 21: Have you ever had any f the following? 1A. Attacks of bronchitis? If yes to 1A: B. Was it confirmed by a doctor? C. At what age was your first attack? 2A. Pneumonia (include bronchopneumonia)? If yes to 2A: Was it confirmed by a doctor? C. At what age did you first have it? 3A. Hay fever? If yes to 3A: B. Was it confirmed by a doctor? C. At what age did it start? Question 22A: Have you ever had chronic bronchitis? If yes to 22A: B. Do you still have it? C. Was it confirmed by a doctor?
D. At what age did it start? Question 23A: Have you ever had emphysema? If yes to 23A: B. Do you still have it? C. Was it confirmed by a doctor? D. At what age did it start? Question 24A: Have you ever had asthma? If yes to 24A: B. Do you still have it? C. Was it confirmed by a doctor? D. At what age did it start? E. If you no longer have it, at what age did it stop? Question 25: Have you ever had: A. Any other chest illness? If yes, please specify. B. Any chest operations? If yes, please specify.
C. Any chest injuries? If yes, please specify. Question 26A: Has a doctor ever told you that you had heart trouble? If yes to 26A: B. Have you ever had treatment for heart trouble in the past 10 years? Question 27A: Has a doctor ever told you that you had high blood pressure? If yes to 27A: B. Have you had any treatment for high blood pressure (hypertension) in the past 10 years? Question 28: When did you last have your chest X-rayed? Question 29: Where did you last have your chext X-rayed (if known)? What was the outcome?
Family History. Question 30: Were either of your natural parents ever told by a doctor that they had a chronic lung condition such as: A. Chronic Bronchitis? B. Emphysema? C. Asthma? D. Lung cancer? E. Other chest conditions? F. Is parent currently alive? G. Please Specify: Age if Living, Age at Death, Don't Know. H. Please specify cause of death. Cough. Question 31A: Do you 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 31C.) B. Do you usually cough as much as 4 to 6 times a day 4 or more days out of the week? C. Do you usually cough at all on getting up or first thing in the morning?
D. Do you usually cough at all during the rest of the day or at night? IF YES TO ANY OF ABOVE (31A, B, C, OR D,), ANSWER THE FOLLOWING. IF NO TO ALL, CHECK "DOES NOT APPLY" AND SKIP TO NEXT PAGE. E. Do you usually cough like this on most days for 3 consecutive months or more during the year? F. For how many years have you had the cough? 32A. Do you 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 32C) B. Do you usually bring up phlegm like this as much as twice a day 4 or more days out of the week? C. Do you usually bring up phlegm at all on getting up or first thing in the morning? D. Do you usually bring up phlegm at all on during the rest of the day or at night? IF YES TO ANY OF THE ABOVE (32A, B, C, OR D), ANSWER THE FOLLOWING: IF NO TO ALL, CHECK "DOES NOT APPLY" AND SKIP TO 33A E. Do you bring up phlegm like this on most days for 3 consecutive months or more during the year? F. For how many years have you had trouble with phlegm?
EPISODES OF COUGH AND PHLEGM. 33A. 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) IF YES TO 33A B. For how long have you had at least 1 such episode per year? WHEEZING. 34A. Does your chest ever sound wheezy or whistling: 1. When you have a cold? 2. Occasionally apart from colds? 3. Most days or nights? B. For how many years has this been present? 35A. Have you ever had an attack of wheezing that has made you feel short of breath? IF YES TO 35A B. How old were you when you had your first attack? C. Have you had 2 or more such episodes? D. Have you ever required medicine or treatment for the(se) attack(s)?
BREATHLESSNESS 36. If disabled from walking by any condition other than heart or lung disease, please describe and proceed to question 38A. 37A. Are you troubled by shortness of breath when hurrying on the level or walking up a slight hill? IF YES TO 37A B. Do you have to walk slower than people of your age on the level because of breathlessness? C. Do you ever have to stop for breath when walking at your own pace on the level? D. Do you ever have to stop for breath after walking about 100 yards (or after a few minutes) on the level? E. Are you too breathless to leave the house or breathless on dressing or climbing one flight of stairs? TOBACCO SMOKING 38A. Have 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.) IF YES TO 38A B. Do you now smoke cigarettes (as of one month ago)
C. How old were you when you first started regular cigarette smoking? D. If you have stopped smoking cigarettes completely, how old were you when you stopped? E. How many cigarettes do you smoke per day now? F. On the average of the entire time you smoked, how many cigarettes did you smoke per day? G. Do or did you inhale the cigarette smoke? 39A. Have you ever smoked a pipe regularly? (Yes means more than 12 oz. of tobacco in a lifetime.) IF YES TO 39A: FOR PERSONS WHO HAVE EVER SMOKED A PIPE B. 1. How old were you when you started to smoke a pipe regularly? 2. If you have stopped smoking a pipe completely, how old were you when you stopped?
C. On the average over the entire time you smoked a pipe, how much pipe tobacco did you smoke per week? D. How much pipe tobacco are you smoking now? E. Do you or did you inhale the pipe smoke? 40A. Have you ever smoked cigars regularly? IF YES TO 40A FOR PERSONS WHO HAVE EVER SMOKED CIGARS B. 1. How old were you when you started smoking cigars regularly? 2. If you have stopped smoking cigars completely, how old were you when you stopped smoking cigars? C. On the average over the entire time you smoked cigars, how many cigars did you smoke per week? D. How many cigars are you smoking per week now? E. Do or did you inhale the cigar
smoke? Signature: Date:
Part 2 PERIODIC MEDICAL QUESTIONNAIRE. 1. Name 2. Clock Number 3. Present Occupation 4. Plant 5. Address 6. ZIP Code 7. Telephone Number 8. Interviewer 9. Date. 10. What is your marital status? 11. Occupational History 11A. In the past year, did you work full time (30 hours per week or more) for 6 months or more? IF YES TO 11A: 11B. In the past year, did you work in a dusty job? l1C. Was dust exposure: l1D. In the past year, were you exposed to gas or chemical fumes in your work? 11E. Was exposure:
11F. In the past year, what was your: 1. Job/occupation? 2. Position/job title? 12. RECENT MEDICAL HISTORY 12A. Do you consider yourself to be in good health? If NO, state reason 12B. In the past year, have you developed: Epilepsy? Rheumatic fever? Kidney disease? Bladder disease? Diabetes? Jaundice? Cancer? 13. CHEST COLDS AND CHEST ILLNESSES 13A. If you get a cold, does it "usually" go to your chest? (usually means more than 1/2 the time) 14A. During the past year, have you had any chest illnesses that have kept you off work, indoors at home, or in bed? IF YES TO 14A: 14B. Did you produce phlegm with any of these chest illnesses? IF YES TO 14A: 14B. Did you produce phlegm with any illnesses with (increased) phlegm did you have which lasted a week or more?
15. RESPIRATORY SYSTEM In the past year have you had: Asthma. Bronchitis. Hay Fever. Other Allergies. Pneumonia. Tuberculosis. Chest Surgery. Other Lung Problems. Heart Disease. Do you have: Frequent colds. Chronic cough. Shortness of breath when walking or climbing one fligth of stairs. Do you: Wheeze. Cough up phlegm. Smoke cigarettes. Date. Signature.