United Lung & Sleep Clinic Asbestos Questionnaire
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1 Date United Lung & Sleep Clinic Asbestos Questionnaire 1. Name,, Last First M.I. 2. Address 3. Home Phone: ( ) - Area Code,, City State Zip Code 4. Social Security # : Birthdate: / / Month Day Year 6. Age: 7. Sex : Male Female 8. Are you currently: Working Retired Unemployed Disabled 9. Primary care provider: Name Telephone #: Address 10. Reason you are seeing the doctor today: 11. If referred; referred by: SR (03/14) Page 1 of 9
2 12. Medical Symptoms Please check the appropriate box for the following symptoms: Symptoms Never Occasionally Regularly A. cough B. wheeze in chest C. hoarseness D. shortness of breath when you exercise E. shortness of breath at night F. chest pain or pressure at exercise G. chest pain or pressure at rest Cough Yes No 13. Do you usually cough as much as 4 to 6 times a day, 4 or more days out of the week? 14. For how many years have you had this cough? 15. Do you usually cough up phlegm as much as twice a day, 4 or more days of the week? 16. Do you usually cough up phlegm when getting up or fi rst thing in the morning? 17. Do you cough up phlegm on most days for 3 consecutive months or more during the year? 18. For how many years have you had trouble with phlegm? Sinus Trouble Yes No 19. Have you had sinus trouble? At what age did it start? SR (03/14) Page 2 of 9
3 Breathlessness Yes No 20. Are you troubled by shortness of breath when hurrying on level ground or walking up a slight hill? 21. Do you have to walk slower than people of your age on level ground because of breathlessness? 22. Do you ever have to stop for a breath when walking at your own pace on level ground? 23. Do you ever have to stop for a breath after walking about 100 yards (or after a few minutes) on level ground? 24. How many fl ights of steps can you walk up without stopping? Please circle: 0 1/ or more Tobacco Use (Cigarettes) Yes No 25. Have you ever smoked cigarettes regularly? (Regularly means more than 20 packs of cigarettes or 12 ounces of tobacco in a lifetime or more than 1 cigarette a day for 1 year) 26. Do you still smoke? 27. If you have stopped smoking cigarettes completely, how old were you when you stopped? 28. How old were you when you fi rst started regularly smoking cigarettes? 29. How many years have you (did you) smoke? (total years) 30. How many cigarettes per day do (did) you smoke on an average? 31. Do (did) you inhale (breathe in) the cigarette smoke? Not at all Slightly Moderately Deeply SR (03/14) Page 3 of 9
4 Tobacco Use (Pipes) 32. Have you ever smoked a pipe regularly? (Yes means more than 12 ounces of tobacco in a lifetime.) Yes No 33. How old were you when you started to smoke a pipe regularly? 34. If you have stopped smoking a pipe completely, how old were you when you stopped? 35. On average, during the entire time you smoked a pipe, how much pipe tobacco did you smoke each week? Tobacco Use (Cigars) 36. Have you ever smoked cigars regularly? (Yes means more than 1 cigar a week for a year) Yes No 37. How old were you when you started smoking cigars regularly? 38. If you have stopped smoking cigars completely, how old were you when you stopped? 39. On the average, during the entire time you smoked cigars, how many cigars did you smoke each week? Tobacco Use (Chewing Tobacco) 40. If you used chewing tobacco, how many years? SR (03/14) Page 4 of 9
5 Medical History Please check the appropriate box for the following medical problems. 41. I have been told by my primary care provider that I have or have had in the past: Yes No A. Asthma B. Emphysema C. Pneumonia D. Other lung diseases E. Broken rib(s) F. High blood pressure (hypertension) G. Heart failure H. Angina (chest pain) I. Abnormal heart rhythm (arrythmia) J. Other medical problems: K. Surgeries: I. Please bring a list of all medicines you are currently taking, including prescription or over the counter medicines or any dietary, herbal, natural or vitamin supplements to your appointment. SR (03/14) Page 5 of 9
6 42. Family History Father Living Any medical problems? Deceased Mother Living Any medical problems? Deceased Brothers & Sisters Number living Any medical problems? Number Deceased 43. Social History Single Married Divorced Widowed Number of children Leisure activities SR (03/14) Page 6 of 9
7 44. Occupational History What is the highest grade level you completed in school? When did you fi nish school? Starting with your fi rst employer up to your current (or most recent) employer, please list your occupations and dates (month/year) employed. Employer(s) From To (month / year) (month / year) First Employer Next Employer Next Employer SR (03/14) Page 7 of 9
8 Next Employer Current (Most Recent) Employer 45. When was your first exposure to asbestos dust? 46. When was your most recent exposure to asbestos dust? 47. Other Exposure History Have you been exposed to any of the following materials in any of your occupations? Yes No Don t Know Silica, sandblasting, or sand dust Coal dust Ammonia TDI (toluene diisocyanate) Sulfur dioxide Formaldehyde Any other toxic material SR (03/14) Page 8 of 9
9 48. Military History Have you served in the military? Check one: Yes No From To If yes, what branch? Army Navy Air Force Marines Other To your knowledge, were you exposed to asbestos during your time in the military? Check one: Yes No If yes, give years of exposure SR (03/14) Page 9 of 9
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