1,3-Butadiene (BD) Initial Health Questionnaire

DIRECTIONS:
You have been asked to answer the questions on this form because you work with BD (butadiene). These questions are about your work, medical history, and health concerns. Please do your best to answer all of the questions. If you need help, please tell the doctor or health care professional who reviews this form.
This form is a confidential medical record. Only information directly related to your health and safety on the job may be given to your employer. Personal health information will not be given to anyone without your consent.

Date: Name: Last First Job Title: Company's Name: Supervisor's Name: Supervisor's Phone No.:

Work History

1 Please list all jobs you have had in the past, starting with the job you have now and moving back in time to your first job. (For more space, write on the back of this page.)

Main Job Duty | Years | Company Name City, State | Chemicals

2 Please describe what you do during a typical work day. Be sure to tell about you work with BD

3 Please check any of these chemicals that you work with now or have worked with in the past

benzene | glues | toluene | inks, dyes | other solvents, grease cutters | insecticides (like DDT, lindane, etc.) | paints, varnishes, thinners, strippers | dusts | carbon tetrachloride ("carbon tet") | arsine | carbon disulfide | lead | cement | petroleum products | nitrites

4. Please check the protective clothing or equipment you use at the job you have now:

gloves | coveralls | respirator | dust mask | safety glasses, goggles

Please circle your answer of yes or no.

5. Does your protective clothing or equipment fit you properly? yes | no

6. Have you ever made changes in your protective clothing or equipment to make it fit better? yes | no

7. Have you been exposed to BD when you were not wearing protective clothing or equipment? yes | no

8. Where do you eat, drink and/or smoke when you are at work? (Please check all that apply.)

Cafeteria/restaurant/snack bar | Break room/employee lounge | Smoking lounge | At my work station

Please circle your answer.

9. Have you been exposed to radiation (like x-rays or nuclear material) at the job you have now or at past jobs? yes | no

10. Do you have any hobbies that expose you to dusts or chemicals (including paints, glues, etc.)? yes | no

11. Do you have any second or side jobs? yes | no

If yes, what are your duties there?

12. Were you in the military? yes | no

If yes, what did you do in the military?

Family Health History

1. In the FAMILY MEMBER column, across from the disease name, write which family member, if any, had the disease.

DISEASE | FAMILY MEMBER

Cancer | Lymphoma | Sickle Cell Disease or Trait | Immune Disease | Leukemia | Anemia

2. Please fill in the following information about family health:

RELATIVE | ALIVE? | AGE AT DEATH? | CAUSE OF DEATH?

Father | Mother | Brother/Sister | Brother/Sister | Brother/Sister

PERSONAL HEALTH HISTORY

Birth Date | Age | Sex | Height | Weight

Please circle your answer.

1. Do you smoke any tobacco products? yes | no

2. Have you ever had any kind of surgery or operation? yes | no

If yes, what type of surgery:

3. Have you ever been in the hospital for any other reasons? yes | no

If yes, please describe the reason:

Do you have any on-going or current medical problems or conditions? yes | no

If yes, please describe:

5. Do you now have or have you ever had any of the following? Please check all that apply to you.

unexplained fever | anemia ("low blood") | HIV/AIDS | weakness | sickle cell | miscarriage | skin rash | bloody stools | leukemia/lymphoma | neck mass/swelling | wheezing | yellowing of skin | bruising easily | lupus | weight loss | kidney problems | enlarged lymph nodes | liver disease | cancer | infertility | drinking problems | thyroid problems | night sweats | chest pain | still birth | eye redness | lumps you can feel | child with birth defect | autoimmune disease | overly tired | lung problems | rheumatoid arthritis | mononucleosis("mono") | nagging cough

Please circle your answer.

6. Do you have any symptoms or health problems that you think may be related to your work with BD? yes | no

If yes, please describe:

7. Have any of your co-workers had similar symptoms or problems? yes | no | don't know

If yes, please describe:

8. Do you notice any irritation of your eyes, nose, throat, lungs or skin when working with BD? yes | no

9. Do you notice any blurred vision, coughing, drowsiness, nausea, or headache when working with BD? yes | no

10. Do you take any medications (including birth control or over-the-counter)? yes | no

If yes, please list:

11. Are you allergic to any medication, food, or chemicals? yes | no

If yes, please list:

12. Do you have any health conditions not covered by this questionnaire that you think are affected by your work with BD? yes | no

If yes, please explain:

13. Did you understand all the questions? yes | no

Signature

1,3-Butadiene (BD) Update Health Questionnaire

DIRECTIONS:

You have been asked to answer the questions on this form because you work with BD (butadiene). These questions ask about changes in your work, medical history, and health concerns since the last time you were evaluated. Please do your best to answer all of the questions. If you need help, please tell the doctor or health care professional who reviews this form. This form is a confidential medical record. Only information directly related to your health and safety on the job may be given to your employer. Personal health information will not be given to anyone without your consent.

Date: | Name: | Last | First | Job Title: | Company's Name: | Supervisor's Name: | Supervisor's Phone No.:

Present Work History

1. Please describe any NEW duties that you have at your job:

2. Please list any additional job titles you have:

Please circle your answer.

3. Are you exposed to any other chemicals in your work since the last time you were evaluated for exposure to BD? yes | no

If yes, please list what they are:

4. Does your personal protective equipment and clothing fit you properly? yes | no

5. Have you made changes in this equipment or clothing to make it fit better? yes | no

6. Have you been exposed to BD when you were not wearing protective equipment or clothing? yes | no

7. Are you exposed to any NEW chemicals at home or while working on hobbies? yes | no

If yes, please list what they are:

8. Since your last BD health evaluation, have you started working any new second or side jobs? yes | no

If yes, what are your duties there?

Personal Health History

1. What is your current weight? | pounds

2. Have you been diagnosed with any new medical conditions or illness since your last evaluation? yes | no

If yes, please tell what they are:

3. Since your last evaluation, have you been in the hospital for any illnesses, injuries, or surgery? yes | no

If yes, please describe:

4. Do you have any of the following?

Please place a check for all that apply to you.

unexplained fever | liver disease | anemia ("low blood") | cancer | HIV/AIDS | infertility | weakness | drinking problems | sickle cell | thyroid problems | miscarriage | night sweats | skin rash | still birth | bloody rash | eye redness | leukemia/lymphoma | lumps you can feel | neck mass/swelling | child with birth defect | wheezing | autoimmune disease | chest pain | overly tired | bruising easily | lung problems | lupus | rheumatoid arthritis | weight loss | mononucleosis "mono" | kidney problems | nagging cough | enlarged lymph nodes | yellowing of skin

Please circle your answer.

5. Do you have any symptoms or health problems that you think may be related to your work with BD? yes | no

If yes, please describe:

6. Have any of your co-workers had similar symptoms or problems? yes | no | don't know

If yes, please describe:

7. Do you notice any irritation of your eyes, nose, throat, lungs, or skin when working with BD? yes | no

8. Do you notice any blurred vision, coughing, drowsiness, nausea, or headache when working with BD? yes | no

9. Have you been taking any NEW medications (including birth control or over-the-counter)? yes | no

If yes, please list:

10. Have you developed any NEW allergies to medications, foods, or chemicals? yes | no

If yes, please list:

11. Do you have any health conditions not covered by this questionnaire that you think are affected by your work with BD? yes | no

If yes, please explain:

12. Did you understand all the questions?

 

12. Did you understand all the questions? yes | no

Signature