14. Revise Appendix D of § 1910.1048 to read as follows:
Appendix D to §1910.1048—Nonmandatory Medical Disease Questionnaire
Identification
Plant Name: _____________________________________________________________
Date: ___________________________________________________________________
Employee Name: _________________________________________________________
Job Title: _______________________________________________________________
Birthdate: _______________________________________________________________
Age: ___________________________________________________________________
Sex: ___________________________________________________________________
Height: _________________________________________________________________
Weight: _________________________________________________________________
Medical History
Have you ever been in the hospital as a patient?
Yes__ No__
If yes, what kind of problem were you having? ____________________________________________________________________________________________________
Have you ever had any kind of operation?
Yes__ No__
If yes, what kind? ___________________________________________________________________________________________________________________________
Do you take any kind of medicine regularly?
Yes__ No__
If yes, what kind? ___________________________________________________________________________________________________________________________
Are you allergic to any drugs, foods, or chemicals?
Yes__ No__
If yes, what kind of allergy is it? _______________________________________________________________________________________________________________
What causes the allergy? _____________________________________________________________________________________________________________________
Have you ever been told that you have asthma, hayfever, or sinusitis?
Yes__ No__
Have you ever been told that you have emphysema, bronchitis, or any other respiratory
problems?
Yes__ No__
Have you ever been told you had hepatitis?
Yes__ No__
Have you ever been told that you had cirrhosis?
Yes__ No__
Have you ever been told that you had cancer?
Yes__ No__
Have you ever had arthritis or joint pain?
Yes__ No__
Have you ever been told that you had high blood pressure?
Yes__ No__
Have you ever had a heart attack or heart trouble?
Yes__ No__
B-1. Medical History Update
Have you been in the hospital as a patient any time within the past year?
Yes__ No__
If so, for what condition? _____________________________________________________________________________________________________________________
Have you been under the care of a physician during the past year?
Yes__ No__
If so, for what condition?_____________________________________________________________________________________________________________________
Is there any change in your breathing since last year?
Yes__ No__
Better? ______________________________________________________________
Worse? ______________________________________________________________
No change?___________________________________________________________
If change, do you know why?__________________________________________________________________________________________________________________
Is your general health different this year from last year?
Yes__ No__
If different, in what way?____________________________________________________________________________________________________________________
Have you in the past year or are you now taking any medication on a regular basis?
Yes__ No__
Name Rx_____________________________________________________________
Condition being treated _________________________________________________
Occupational History
How long have you worked for your present employer?
_____________________________________________________________________
What jobs have you held with this employer? Include job title and length of time
in each job __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
In each of these jobs, how many hours a day were you exposed to chemicals?
_____________________________________________________________________
What chemicals have you worked with most of the time?
_____________________________________________________________________
Have you ever noticed any type of skin rash you feel was related to your work?
Yes__ No__
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__
Are you exposed to any dust or chemicals at home?
Yes__ No__
If yes, explain: _____________________________________________________________________________________________________________________________
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
Are you working on the same job this year as you were last year?
Yes__ No__
If not, how has your job changed? ______________________________________________________________________________________________________________
What chemicals are you exposed to on your job?
_____________________________________________________________________
How many hours a day are you exposed to chemicals?
_____________________________________________________________________
Have you noticed any skin rash within the past year you feel was related to your work?
Yes__ No__
If so, explain circumstances: __________________________________________________________________________________________________________________
Have you noticed that any chemical makes you cough, be short of breath, or wheeze?
Yes__ No__
If so, can you identify it? _____________________________________________________________________________________________________________________
Miscellaneous
Do you smoke?
Yes__ No__
If so, how much and for how long? _____________________________________________________________________________________________________________
Pipe_________________________________________________________________
Cigars_______________________________________________________________
Cigarettes____________________________________________________________
Do you drink alcohol in any form?
Yes__ No__
If so, how much, how long, and how often? _____________________________________________________________________________________________________
Do you wear glasses or contact lenses?
Yes__ No__
Do you get any physical exercise other than that required to do your job?
Yes__ No__
If so, explain: ______________________________________________________________________________________________________________________________
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.
_____________________________________________________________________
Symptoms Questionnaire
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__
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__
Do you ever have a feeling of smothering, unable to take a deep breath, or tightness in
your chest?
Yes__ No__
If yes, do you notice that this on any particular day of the week?
Yes__ No__
If yes, what day or the week?
Yes__ No__
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__
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? ___________________________________________________
Have you noticed any burning, tearing, or redness of your eyes when you are at work?
Yes__ No__
If so, explain circumstances: _____________________________________________
_____________________________________________________________________
Have you noticed any sore or burning throat or itchy or burning nose when you are at work?
Yes__ No__
If so, explain circumstances: __________________________________________________________________________________________________________________
Have you noticed any stuffiness or dryness of your nose?
Yes__ No__
Do you ever have swelling of the eyelids or face?
Yes__ No__
Have you ever been jaundiced?
Yes__ No__
If yes, was this accompanied by any pain?
Yes__ No__
Have you ever had a tendency to bruise easily or bleed excessively?
Yes__ No__
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? ___________________________________________________________________________________________________________________
Do you have frequent episodes of nervousness or irritability?
Yes__ No__
Do you tend to have trouble concentrating or remembering?
Yes__ No__
Do you ever feel dizzy, light-headed, and excessively drowsy or like you have been drugged?
Yes__ No__
Does your vision ever become blurred?
Yes__ No__
Do you have numbness or tingling of the hands or feet or other parts of your body?
Yes__ No__
Have you ever had chronic weakness or fatigue?
Yes__ No__
Have you ever had any swelling of your feet or ankles to the point where you could not
Yes__ No__
Are you bothered by heartburn or indigestion?
Yes__ No__
Do you ever have itching, dryness, or peeling and scaling of the hands?
Yes__ No__
Do you ever have a burning sensation in the hands, or reddening of the skin?
Yes__ No__
Do you ever have cracking or bleeding of the skin on your hands?
Yes__ No__
Are you under a physician's care?
Yes__ No__
If yes, for what are you being treated? ___________________________________________________________________________________________________________
Do you have any physical complaints today?
Yes__ No__
If yes, explain? _____________________________________________________________________________________________________________________________
Do you have other health conditions not covered by these questions?
Yes__ No__
If yes, explain: ____________________________________________________________________________________________________________________________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Harper, Hiliary - OSHA |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |