Subchapter 7. General Industry Safety Orders
Group 16. Control of Hazardous Substances
Article 110. Regulated Carcinogens

§5217. Formaldehyde, Appendix D

        Nonmandatory Medical Disease Questionnaire 
 
 A. Identification 
 
 Plant Name: ______________________ 
 Date: ____________________________
 Employee Name: ___________________
 S.S. #: __________________________
 Job Title: _______________________
 Birthdate: _______________________
 Age: _____________________________
 Sex: _____________________________
 Height: __________________________
 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? 
____________________________________________
 2. Have you ever had any kind of operation? 
              Yes [ ]  No [ ]

If yes, what kind?
____________________________________________

 3. Do you take any kind of medicine regularly? 
               Yes [ ]  No [ ]

 If yes, what kind? 
 ____________________________________________

 4. Are you allergic to any drugs, foods, or chemicals? 
               Yes [ ]  No [ ]

If yes, what kind of allergy is it? 
____________________________________________

What causes the allergy? 
____________________________________________

 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 [ ]
 If so, for what condition?______________________ 
 2. Have you been under the care of a physician during
 the past year?  
                 Yes [ ]  No [ ]

 If so, for what condition? 
 ____________________________________________

 3. Is there any change in your breathing since last year? 
                  Yes [ ]  No [ ]

Better? ___________________________________________
Worse? ____________________________________________
No change? ________________________________________
If change, do you know why? _______________________

 4. Is your general health different this year from last year?  
                   Yes [ ]  No [ ]

If different, in what way? 
____________________________________________
 5. Have you in the past year or are you now taking any
 medication on a regular basis? 
                   Yes [ ]  No [ ]

Name Rx ____________________________________________
Condition being treated ____________________________

C.  Occupational History 
  
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. 
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________

3. In each of these jobs, how many hours a day were you
exposed to chemicals? 
____________________________________________
____________________________________________  

4. What chemicals have you worked with most of the time? 
____________________________________________


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 [ ]

If not, how has your job changed? 
____________________________________________

2. What chemicals are you exposed to on your job? 
____________________________________________
  
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 [ ]

If so, how much and for how long? 
____________________________________________

Pipe________________________________________
 
Cigars _____________________________________

Cigarettes _________________________________

 2. Do you drink alcohol in any form? 
                      Yes [ ]  No [ ]

If so, how much, how long, and how often? 
____________________________________________

 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 hearurn 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: 
____________________________________________
____________________________________________
____________________________________________