MINNESOTA OCCUPATIONAL HEALTH 1661 St Anthony Avenue St Paul, MN Telephone (651) Fax (651)
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1 MINNESOTA OCCUPATIONAL HEALTH 1661 St Anthony Avenue St Paul, MN Telephone (651) Fax (651) PERIODIC HAZMAT/ASBESTOS MEDICAL QUESTIONNAIRE Date: / / NAME: SS#: - - COMPANY: 1. OCCUPATIONAL HISTORY A. Have you ever worked full time (30 hours per week or more) for 6 months or more? 1. Yes 2. No IF YES, TO 1B: B. Have you ever worked for a year or more in any dusty job? 1. Yes 2. No 3. Does not apply Specific job/industry: Total years worked Was dust exposure: 1. Mild 2. Moderate 3. Severe C. Have you ever been exposed to gas or chemical fumes in your work? 1. Yes 2. No Specific job/industry Total years worked Was exposure: 1. Mild 2. Moderate 3. Severe D. In the past year what was your: 1. Job occupation 2. Position/job title RECENT MEDICAL HISTORY A. Do you consider yourself to be in good health? 1. Yes 2. No If NO, state reason
2 1. In the past, have you developed: 1. Epilepsy (or fits, seizures, convulsions)? 1. Yes 2. No 2. Rheumatoid fever? 1. Yes 2. No 3. Kidney disease? 1. Yes 2. No 4. Bladder disease? 1. Yes 2. No 5. Diabetes? 1. Yes 2. No 6. Jaundice? 1. Yes 2. No 7. Cancer? 1. Yes 2. No 1CHEST COLDS AND CHEST ILLNESSES A. If you get a cold, does it usually go to your chest? 1. Yes 2. No (Usually means more than 1/2 the time) 3. Don t get colds B. During the past year, 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 C C. Did you produce phlegm with any of these chest illnesses? 1. Yes 2. No 3. Does not apply D. In the last year, how many such illnesses with (increased) Number of illnesses phlegm did you have which lasted a week or more? RESPIRATORY SYSTEM In the past have you had: 1. Asthma: 1. Yes 2. No Comments on positive answer: 2. Bronchitis: 1. Yes 2. No Comments on positive answer: 3. Hay fever: 1. Yes 2. No Comments on positive answer: 4. Pneumonia: 1. Yes 2. No Comments on positive answer: 5. Tuberculosis: 1. Yes 2. No Comments on positive answer:
3 6. Chest Surgery: 1. Yes 2. No Comments on positive answer: 7. Other lung problems: 1. Yes 2. No Comments on positive answer: 8. Heart disease: 1. Yes 2. No Comments on positive answer: 9. Frequent colds: 1. Yes 2. No Comments on positive answer: 10. Chronic Cough: 1. Yes 2. No Comments on positive answer: 11. Shortness of breath with walking/climbing one flight of stairs 1. Yes 2. No Comments on positive answer: DO YOU: 1. Wheeze: 1. Yes 2. No Comments on positive answer: 2. Cough up phlegm: 1. Yes 2. No Comments on positive answer: 3. Smoke Cigarettes: 1. Yes 2. No Comments on positive answer: Date Employee Signature
4 FOR OFFICE USE ONLY Name of Employee Company Height Weight Blood Pressure Pulse min. Post exercise pulse min. Smoking: Yes No # of Years Chest x-ray within normal limits: Yes No N/A Spirometry results within normal limits: Yes No N/A HEENT Cardiopulmonary: N Ab N Ab outer ear ( ) ( ) percussion ( ) ( ) ear canal ( ) ( ) auscultation ( ) ( ) TM s ( ) ( ) carotid pulses ( ) ( ) nasal mucosa ( ) ( ) heart sounds ( ) ( ) lips ( ) ( ) radial pulses ( ) ( ) tongue ( ) ( ) extremities ( ) ( ) oropharynx ( ) ( ) neck ( ) ( ) trachea ( ) ( )
5 MINNESOTA OCCUPATIONAL HEALTH 1661 St Anthony Avenue St Paul, MN Telephone (651) Fax (651) Name of Employee Social Security # - - Company PHYSICIAN S EXAMINATION AND FINDINGS (To be completed by Physician) I have examined the individual named above and find: (circle one) 1. No physical or medical reason to prohibit this employee from participation in a program which may require the use of respirators. 2. Physical or medical reasons require the following restrictions on participation in a program which may require the use of respirators. 3. No respirator use is permitted for this individual at this time. The employee has been informed by me (the undersigned physician) of the results of the medical examination, increased risk of lung cancer attributable to the combined effect of smoking and asbestos exposure. Yes No N/A Physician Signature_ Physician Name (Please type or print) Address 1661 St Anthony Avenue, St Paul, MN Phone Number (615) Date / /
6 Minnesota Occupational Health Integrated, Comprehensive Occupational Health Services ASBESTOS SUMMARY REPORT Patient Name: The results of my examination HAVE NOT ( ) HAVE ( ) detected a medical condition which would place the employee at an increased risk of material health impairment from exposure to asbestos; and In accordance with OSHA requirements, I have informed the above named individual of the results of his/her medical examination and of any medical condition that may result from his/her exposure to asbestos. Physicians Signature Date
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