Cal. Code Regs. Tit. 8, div. 1, ch. 4, subch. 7, grp. 16, art. 110, app D to Section 5217
A. Identification
___________________________
Plant Name:
___________________________
Date:
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Employee Name:
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S.S. #:
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Job Title:
___________________________
Birthdate:
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Age:
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Sex:
___________________________
Height:
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Weight:
B. Medical History
1. Have you ever been in the hospital as a patient?
| Yes [] | No [] |
If yes, what kind of problem were you having?
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2. Have you ever had any kind of operation?
| Yes [] | No [] |
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If yes, what kind?
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3. Do you take any kind of medicine regularly?
| Yes [] | No [] |
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If yes, what kind?
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4. Are you allergic to any drugs, foods, or chemicals?
| Yes [] | No [] |
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If yes, what kind of allergy is it?
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___________________________
What causes the allergy?
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5. Have you ever been told that you have asthma, hayfever, or sinusitis?
| Yes [] | No [] |
6. Have you ever been told that you have emphysema, bronchitis, or any other respiratory problems?
| Yes [] | No [] |
7. Have you ever been told that you had hepatitis?
| Yes [] | No [] |
8. Have you ever been told that you had cirrhosis?
| Yes [] | No [] |
9. Have you ever been told that you had cancer?
| Yes [] | No [] |
10. Have you ever had arthritis or joint pain?
| Yes [] | No [] |
11. Have you ever been told that you had high blood pressure?
| Yes [] | No [] |
12. Have you ever had a heart attack or heart trouble?
| Yes [] | No [] |
B-1. Have Medical History Update
1. Have you been in the hospital as a patient any time within the past year?
| Yes [] | No [] |
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If so, for what condition?
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2. Have you been under the care of a physician during the past year?
| Yes [] | No [] |
___________________________
If so, for what condition?
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3. Is there any change in your breathing since last year?
| Yes [] | No [] |
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Better?
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Worse?
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No change?
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If change, do you know why?
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4. Is your general health different this year from last year?
| Yes [] | No [] |
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If different, in what way?
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5. Have you in the past year or are you now taking any medication on a regular basis?
| Yes [] | No [] |
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Name Rx
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Condition being treated
C. Occupational History
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1. How long have you worked for your present employer?
___________________________
___________________________
2. What job have you held with this employer?
Include job title and length in each job.
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___________________________
___________________________
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3. In each of these jobs, how many hours a day were you exposed to chemicals?
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4. What chemicals have you worked with most of the time? _
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5. Have you ever noticed any type of skin rash you feel was related to your work?
| Yes [] | No [] |
6. Have you ever noticed that any kind of chemical makes you cough?
| Yes [] | No [] |
Wheeze?
| Yes [] | No [] |
Become short of breath or cause your chest to become tight?
| Yes [] | No [] |
7. Are you exposed to any dust or chemicals at home?
| Yes [] | No [] |
___________________________
If yes, explain:
___________________________
___________________________
8. In other jobs, have you ever had exposure to:
Wood dust?
| Yes [] | No [] |
Nickel or chromium?
| Yes [] | No [] |
Silica (foundry, sand blasting)?
| Yes [] | No [] |
Arsenic or asbestos?
| Yes [] | No [] |
Organic solvents?
| Yes [] | No [] |
Urethane foams?
| Yes [] | No [] |
C-1. Occupational History Update
1. Are you working on the same job this year as you were last year?
| Yes [] | No [] |
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If not, how has your job changed?
___________________________
___________________________
2. What chemicals are you exposed to on your job?
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___________________________
3. How many hours a day are are exposed to chemicals?
4. Have you noticed any skin rash within the past year you feel was related to your work?
| Yes [] | No [] |
___________________________
If so, explain circumstances:
___________________________
5. Have you noticed that any chemical makes you cough, be short of breath, or wheeze?
| Yes [] | No [] |
___________________________
If so, can you identify it?
___________________________
D. Miscellaneous
1. Do you smoke?
| Yes [] | No [] |
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If so, how much and for how long?
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___________________________
Pipe
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Cigars
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Cigarettes
2. Do you drink alcohol in any form?
| Yes [] | No [] |
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If so, how much, how long, and how often?
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3. Do you wear glasses or contact lenses?
| Yes [] | No [] |
4. Do you get any physical exercise other than that required to do your job?
| Yes [] | No [] |
___________________________
If so, explain:
___________________________
5. Do you have any hobbies or "side jobs" that require you to use chemicals, such as furniture stripping, sand blasting, insulation or manufacture of urethane foam, furniture, etc?
| Yes [] | No [] |
If so, please describe, giving type of business or hobby, chemicals used and length of exposures.
___________________________
___________________________
E. Symptoms Questionnaire
1. Do you ever have any shortness of breath?
| Yes [] | No [] |
If yes, do you have to rest after climbing several flights of stairs?
| Yes [] | No [] |
If yes, if you walk on the level with people your own age, do you walk slower than they do?
| Yes [] | No [] |
If yes, if you walk slower than a normal pace, do you have to limit the distance that you walk?
| Yes [] | No [] |
If yes, do you have to stop and rest while bathing or dressing?
| Yes [] | No [] |
2. Do you cough as much as three months out of the year?
| Yes [] | No [] |
If yes, have you had this cough for more than two years?
| Yes [] | No [] |
If yes, do you ever cough anything up from chest?
| Yes [] | No [] |
3. Do you ever have a feeling of smothering, unable to take a deep breath, or tightness in you chest?
| Yes [] | No [] |
If yes, do you notice this condition on any particular day of the week?
| Yes [] | No [] |
___________________________
If yes, what day of the week?
If yes, do you notice that this occurs at any particular place?
| Yes [] | No [] |
If yes, do you notice that this is worse after you have returned to work after being off for several days?
| Yes [] | No [] |
4. Have you ever noticed any wheezing in your chest?
| Yes [] | No [] |
If yes, is this only with colds or other infections?
| Yes [] | No [] |
Is this caused by exposure to any kind of dust or other material?
| Yes [] | No [] |
___________________________
If yes, what kind?
5. Have you noticed any burning, tearing, or redness of your eyes when you are at work?
| Yes [] | No [] |
___________________________
If so, explain circumstances:
___________________________
6. Have you noticed any sore or burning throat or itchy or burning nose when you are at work?
| Yes [] | No [] |
___________________________
If so, explain circumstances:
___________________________
7. Have you noticed any stuffiness or dryness of your nose?
| Yes [] | No [] |
8. Do you ever have swelling of the eyelids or face?
| Yes [] | No [] |
9. Have you ever been jaundiced?
| Yes [] | No [] |
If yes, was this accompanied by any pain?
| Yes [] | No [] |
10. Have you ever had a tendency to bruise easily or bleed excessively?
| Yes [] | No [] |
11. Do you have frequent headaches that are not relieved by aspirin or Tylenol?
| Yes [] | No [] |
If yes, do they occur at any particular time of the day or week?
| Yes [] | No [] |
___________________________
If yes, when do they occur?
___________________________
12. Do you have frequent episodes of nervousness or irritability?
| Yes [] | No [] |
13. Do you tend to have trouble concentrating or remembering?
| Yes [] | No [] |
14. Do you ever feel dizzy, light-headed, excessively drowsy or like you have been drugged?
| Yes [] | No [] |
15. Does your vision ever become blurred?
| Yes [] | No [] |
16. Do you have numbness or tingling of the hands or feet or other parts of your body?
| Yes [] | No [] |
17. Have you ever had chronic weakness or fatigue?
| Yes [] | No [] |
18. Have you ever had any swelling of your feet or ankles to the point where you could not wear your shoes?
| Yes [] | No [] |
19. Are you bothered by heartburn or indigestion?
| Yes [] | No [] |
20. Do you ever have itching, dryness, or peeling and scaling of the hands?
| Yes [] | No [] |
21. Do you ever have a burning sensation in the hands or reddening of the skin?
| Yes [] | No [] |
22. Do you ever have cracking or bleeding of the skin on your hands?
| Yes [] | No [] |
23. Are you under a physician's care?
| Yes [] | No [] |
___________________________
If yes, for what are you being treated?
___________________________
24. Do you have any physical complaints today?
| Yes [] | No [] |
___________________________
If yes, explain:
___________________________
25. Do you have other health conditions not covered by these questions?
| Yes [] | No [] |
___________________________
If yes, explain:
___________________________
Cal. Code Regs. Tit. 8, div. 1, ch. 4, subch. 7, grp. 16, art. 110, app D to Section 5217