Medical survey control card

Attachment 5 Medical survey Contol Card.pptx

Understanding Long-term Respiratory Morbidity in Former Styrene-exposed Workers: Medical Survey

Medical survey control card

OMB: 0920-1332

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 Subject ID

 Name

 Birthdate

 Age

 Gender

      M       F

 Ethnicity

 (Hispanic)      Y       N

 Race

 AmIn     As     Bl     PI     Wh

 Smoke

  C      F      N

 Height (nearest ½ inch)

 Weight (pounds)

 Blood Pressure

 Pulse

 

 Current Medications/Eye Drops/Inhalers

INITIAL WHEN COMPLETE

 Questionnaire

 FENO

 Multiple-Breath Washout

 IOS

 Spirometry

 Bronchodilator

 Color Vision Testing

Spirometry Contraindications:  YES / NO

Within the last 3 months: chest pain (angina), heart attack, stroke , eye surgery (including LASIK, PRK, or cataract surgery), chest surgery (including heart procedure), abdominal surgery, and head surgery (including brain or ear surgery).

Ever:  coughing up blood (hemoptysis), collapsed lung (pneumothorax), arterial aneurysm of the belly or brain, or detached retina

Current: gastrointestinal distress, chest discomfort, back discomfort, treatment (anticoagulant) for pulmonary embolism, require supplemental oxygen

Systolic BP >180, diastolic BP >110, pulse >110 bpm

Bronchodilator Contraindications:  YES / NO

Have you ever been diagnosed by a healthcare professional with an irregular heart beat (arrhythmia)

Have you ever had a seizure?

Have you ever had an adverse reaction to albuterol such as tremors, palpitations, fast heart rate, hypertension, fainting, dizziness, headache, upset stomach, or skin rashes

Systolic BP >160, diastolic BP >100

Pulse >100 bpm

Physician’s signature:______________________________________________

FeNO Contraindications:  YES / NO

Do you have a breathing problem requiring oxygen or problems taking deep breaths?

 
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