University of Maryland University Health Center. Initial Asbestos Questionnaire

Transcription

1 UniversityofMaryland UniversityHealthCenter InitialAsbestosQuestionnaire Name: UID: Date: HomeAddress: Dept: Position: Supervisor: HomePhone: WorkPhone: WorkE mailaddress: Dateofbirth: PatientInformation: a. Areyoucurrentlybeingtreatedbyadoctorforanyillnessorinjury? Yes No Ifyespleaselist: b. Areyoucurrentlytakinganyprescriptions,non prescriptions,orherbalmedications? Yes No Ifyes,listmedicines: c. Ifyouhaveseenadoctorinthepast6weeks,statewhy: d. Listanyfood,drug,orchemicalallergiesyouhave: e. Placeofbirth: f. Sex:Male Female Transgendered Other g. MaritalStatus: Single Married Widowed Separated/Divorced h. Race:White Black Asian Hispanic Indian Other i. Whatisthehighestgradecompletedinschool?(Forexample12yearsiscompletionofhigh school) j. AreyouintheAsbestosProgram? Yes No k. AreyouintheVoluntaryAsbestosProgram? Yes No l. Doyouweararespiratorforanyotherpurposeatwork? Yes No Whatkind? andforwhatpurpose? OccupationalHistory: a. Haveyoueverworkedfulltime(30hours/week)for6monthsormore? Yes No IfyestoA: b. Haveyoueverworkedforayearormoreinanydustyjob?Yes No Doesn tapply Specifyjob/industry: Totalyearsworked Wasdustexposure: Mild Moderate Severe c. Haveyoueverbeenexposedtogasorchemicalfumesinyourwork? Yes No Specifyjob/industry: Totalyearsworked Wasexposure: Mild Moderate Severe d. Whathasbeenyourusualoccupationorjob theoneyouhaveworkedatthelongest? 1.Joboccupation 2.Numberofyearsemployedatthisoccupation 3.Position/jobtitle 4.Business,fieldorindustry (Recordonlinestheyearsinwhichyouhaveworkedinanyoftheseindustries,e.g )

2 e. Inthepastyear,whatwasyour: 1.Job/occupation? 2.Position/jobtitle? Haveyoueverworked: f. Inamine? Yes No i.inacotton,flaxorhempmill?yes No g. Inapottery? Yes No j.inafoundry? Yes No h. Inaquarry? Yes No k.withasbestos? Yes No PastMedicalHistory: a. Doyouconsideryourselftobeingoodhealth? Yes No Ifnostatereason b. Haveyouanydefectofvision? Yes No Ifyesstatenatureofdefect c. Haveyouanyhearingdefect? Yes No Ifyesstatenatureofdefect d. Areyousufferingfromorhaveyoueversufferedfrom: 1. Epilepsy(orfits,seizures,convulsions)? Yes No 2. Rheumaticfever? Yes No 3. Kidneydisease? Yes No 4. Bladderdisease? Yes No 5. Diabetes? Yes No ChestColdsandChestIllnesses: 1. Ifyougetacold,doesit usually gotoyourchest? Yes No Don tgetcolds (Usuallymeansmorethan1/2thetime) 2. Duringthepast3years,haveyouhadanychestillnessesthathavekeptyouoffwork, indoorsathome,orinbed? Yes No Ifyesto2: a. Didyouproducephlegmwithanyofthesechestillnesses? Yes No Doesn tapply b. Inthelast3years,howmanysuchillnesseswith(increased)phlegmdidyouhavewhich lastedaweekormore? Numberofillnesses Nosuchillnesses 3.Didyouhaveanylungtroublebeforetheageof16? Yes No 4.Haveyoueverhadanyofthefollowing? a. Attacksofbronchitis? Yes No Ifyesto4A: 1)Wasitconfirmedbyadoctor? Yes No Doesn tapply 2)Atwhatagewasyourfirstattack? Ageinyears Doesn tapply b. Pneumonia(includebronchopneumonia)? Yes No Ifyesto4B: 1)Wasitconfirmedbyadoctor?Yes No Doesn tapply 2)Atwhatagedidyoufirsthaveit? Ageinyears Doesn tapply c. HayFever? Yes No

3 Ifyesto4C: 1)Wasitconfirmedbyadoctor? Yes No Doesn tapply 2)Atwhatagediditstart? Ageinyears Doesn tapply 5. Haveyoueverhadchronicbronchitis? Yes No Ifyesto5: a. Doyoustillhaveit? Yes No Doesn tapply b. Wasitconfirmedbyadoctor? Yes No Doesn tapply c. Atwhatagediditstart? Ageinyears Doesn tapply 6. Haveyoueverhademphysema? Yes No Ifyesto6: a. Doyoustillhaveit? Yes No Doesn tapply b. Wasitconfirmedbyadoctor? Yes No Doesn tapply c. Atwhatagediditstart? Ageinyears Doesn tapply 7. Haveyoueverhadasthma? Yes No Ifyesto7: a. Doyoustillhaveit? Yes No Doesn tapply b. Wasitconfirmedbyadoctor? Yes No Doesn tapply c. Atwhatagediditstart? Ageinyears Doesn tapply d. Ifyounolongerhaveit,atwhatagediditstop? Agestopped Doesn tapply 8. Haveyoueverhad: a. Anyotherchestillness? Yes No Ifyes,pleasespecify b. Anychestoperations? Yes No Ifyes,pleasespecify c. Anychestinjuries? Yes No Ifyes,pleasespecify 9. Hasadoctorevertoldyouthatyouhadhearttrouble? Yes No Ifyesto9: a. Haveyouhadanytreatmentforhearttroubleinthepast10years? Yes No Doesn tapply 10. Hasadoctortoldyouthatyouhadhighbloodpressure? Yes No Ifyesto10: Haveyouhadanytreatmentforhighbloodpressure(hypertension)inthepast10years? Yes No Doesn tapply 11. WhendidyoulasthaveyourchestX rayed?year 12. WheredidyoulasthaveyourchestX rayed(ifknown)? FamilyHistory: 1.Wereeitherofyournaturalparentsevertoldbyadoctorthattheyhadachroniclung conditionsuchas: Father Mother Yes NoDon tknow Yes No Don tknow a. Chronicbronchitis? b. Emphysema? c. Asthma? d. Lungcancer?

4 Father Mother YesNoDon tknow YesNoDon tknow e. Otherchestconditions? f. Isparentcurrentlyalive? g. Pleasespecify: Ageifliving Ageifliving Ageatdeath Ageatdeath Don tknow Don tknow h. Pleasespecifycauseofdeath Cough: 1. Doyouusuallyhaveacough?(Countacoughwithfirstsmokeorfirstgoingoutofdoors. Excludeclearingofthroat.) Yes No Ifno,skiptoquestion1B a. Doyouusuallycoughasmuchas4to6timesadayormoredaysoutoftheweek? Yes No b. Doyouusuallycoughatallongettinguporfirstthinginthemorning?Yes No c. Doyouusuallycoughatallduringtherestofthedayoratnight?Yes No Whatwastheoutcome? IFYESTOANYOFTHEABOVE(1A,B,C),ANSWERTHEFOLLOWING.IFNOTOALL,CHECK DOESN TAPPLYANDSKIPTOWHEEZING#1. d. Doyouusuallycoughlikethisonmostdaysfor3consecutivemonthsormoreduring theyear? Yes No Doesn tapply e. Forhowmanyyearshaveyouhadthecough? Numberofyears Doesn tapply 1. Doyouusuallybringupphlegmfromyourchest?(countphlegmwiththefirstsmokeoron firstgoingoutofdoors.excludephlegmfromthenose.countswallowedphlegm.) Yes No Ifno,skipto2B a. Doyouusuallybringupphlegmlikethisasmuchastwiceadayor4ormoredaysout oftheweek? Yes No b. Doyouusuallybringupphlegmatallongettinguporfirstthinginthemorning? Yes No c. Doyouusuallybringupphlegmatallduringtherestofthedayoratnight? Yes No IfYEStoanyoftheabove(2,A,B,ORC),answerthefollowing.IfNOtoall,checkdoesn t applyandskipto1a. d. Doyoubringupphlegmlikethisonmostdaysfor3consecutivemonthsormore duringtheyear? Yes No Doesn tapply e. Forhowmanyyearshaveyouhadtroublewithphlegm? Numberofyears Doesn tapply Episodesofcoughandphlegm: 1. Haveyouhadperiodsorepisodesof(increased*)coughandphlegmlastingfor3weeksor moreeachyear?*forpersonswhousuallyhavecoughand/orphlegm Yes No

5 Ifyesto1: a. Forhowlonghaveyouhadatleastonesuchepisodeperyear? Numberofyears Doesn tapply Wheezing: 1.Doesyourchesteversoundwheezyorwhistling? a. Whenyouhaveacold? Yes No b. Occasionallyapartfromcolds? Yes No c. Mostdaysornights? Yes No IfyestoA,BorC: d. Orhowmanyyearshasthisbeenpresent?Numberofyears Doesn tapply 2. Haveyoueverhadanattackofwheezingthathasmadeyoufeelshortofbreath? Yes No Doesn tapply Ifyesto2: a. Howoldwereyouwhenyouhadyourfirstsuchattack? Ageinyears Doesn tapply b. Haveyouhad2ormoresuchepisodes? Yes No Doesn tapply c. Haveyoueverrequiredmedicineortreatmentforthe(se)attack(s)? Yes No Doesn tapply Breathlessness: 1. Ifdisabledfromwalkingbyanyconditionotherthanheartorlungdisease,pleasedescribe andproceedtotobaccosmoking#1. Natureofcondition(s) 2. Areyoutroubledbyshortnessofbreathwhenhurryingonthelevelorwalkingupaslight hill? Yes No Ifyesto2: a. Doyoueverwalkslowerthanpeopleofyourageonthelevelbecauseof breathlessness? Yes No Doesn tapply b. Doyoueverstopforbreathwhenwalkingatyourownpaceonthelevel? Yes No Doesn tapply c. Doyoueverhavetostopforbreathafterwalkingabout100yards(orafterafew minutes)onthelevel? Yes No Doesn tapply d. Areyoutoobreathlesstoleavethehouseorbreathlessondressingorclimbingone flightofstairs? Yes No Doesn tapply TobaccoSmoking: 1. Haveyoueversmokedcigarettes?(Nomeanslessthan20packsofcigarettesor12oz.of tobaccoinalifetimeorlessthanonecigaretteadayforoneyear) Yes No Ifyesto1: a. Doyounowsmokecigarettes?(asofonemonthago)Yes No Doesn tapply b. Howoldwereyouwhenyoufirststartedregularcigarettesmoking? Ageinyears Doesn tapply c. Ifyouhavestoppedsmokingcigarettescompletely,howoldwereyouwhenyou stopped? Ageifstopped Stillsmoking d. Howmanycigarettesdoyousmokeperdaynow? Cigarettesaday Doesn tapply

6 e. Ontheaverageoftheentiretimesmoked,howmanycigarettesdidyousmokeper day? Cigarettesaday Doesn tapply f. Doordidyouinhalethecigarettesmoke? Doesn tapply Notatall Slightly Moderately Deeply 2. Haveyoueversmokedapiperegularly?(Yesmeansmorethan12oz.oftobaccoina lifetime) Yes No Ifyesto2: a. Howoldwereyouwhenyoustartedtosmokeapiperegularly?Age b. Ifyouhavestoppedsmokingapiperegularly,howoldwereyouwhenyoustopped? Ageifstopped Stillsmoking c. Ontheaverageovertheentiretimeyousmokedapipe,howmuchpipetobaccodidyou smokeperweek? oz.perweek(astandardpouchoftobaccocontains11/2 oz.) d. Howmuchpipetobaccoareyousmokingnow? oz.perweek Notcurrentlysmokingapipe e. Doyouordidyouinhalethepipesmoke? Neversmoked Notatall Slightly Moderately Deeply 3. Haveyoueversmokedcigarsregularly?(Yesmeansmorethan1cigaraweekforayear) Yes No Ifyesto3: a. Howoldwereyouwhenyoustartedsmokingcigarsregularly?Age b. Ifyouhavestoppedsmokingcigarscompletely,howoldwereyouwhenyoustopped? Agestopped Stillsmoking c. Ontheaverageovertheentiretimeyousmokedcigars,howmanycigarsdidyousmoke perweek? CigarsperweekDoesn tapply d. Howmanycigarsareyousmokingperweeknow? CigarsperweekNotcurrentlysmokingcigars e. Doordidyouinhalethecigarsmoke? Neversmoked Notatall Slightly Moderately Deeply Iunderstandthatthisphysicalexaminationisnotdesigned,norintended,toreplacearegular physicalexamination,orroutinemedicalcare,bymyprivatephysician.iunderstandthatthis examination and all subsequent examinations are highly specific to evaluate my ability to performcertaintasksnotedinmyjobdescription.thisexaminationwillnotcoverallaspectsof afullphysicalexamination. Signature Date Revised5.10