OSHA Medical Asbestos Questionnaire

Sparrow Occupational Health Services
OSHA Medical Asbestos Questionnaire (Mandatory - 1910.1001 App D, Part II)
Periodic Medical Questionnaire

This questionnaire needs to be filled out annually by employees who have already completed baseline testing.
  
*
Name
*
Last 4 digits of Social Security #:
*
Birthdate
*
Present Occupation
*
Employer Name
*
Employer Address
*
Zip Code
*
Daytime Telephone (format: 123-123-1234)
Marital Status

Single, Separated/Divorced, Married, or Widowed

Email Address
Today's Date

OCCUPATIONAL HISTORY

*
12. A. Have you ever worked full time (30 hours per week or more) for 6 months or more?

Yes or No

B. In the past year, did you work in a dusty job?

Yes, No, or Does not Apply

C. Was dust exposure:

Mild, Moderate, or Severe

D. In the past year, have you been exposed to gas or chemical fumes in your work?

Yes or No

E. Was exposure:

Mild, Moderate, or Severe

F. In the past year, what was your:

1. Job Occupation:
2. Position/Job Title:

RECENT MEDICAL HISTORY

*
13. A. Do you consider yourself to be in good health?

Yes or No

If "No" state reason:

B. In the past year, have you developed:

*
1. Epilepsy (fits, seizures, convulsions)?

Yes or No

*
2. Rheumatic fever?

Yes or No

*
3. Kidney disease?

Yes or No

*
4. Bladder disease?

Yes or No

*
5. Diabetes?

Yes or No

*
6. Jaundice?

Yes or No

*
7. Cancer?

Yes or No

CHEST COLDS AND CHEST ILLNESSES

*
14. If you get a cold, does it "usually" go to your chest? (Usually means more than 1/2 the time.)

Yes, No, or Don't get colds

*
15. A. During the past year, have you had any chest illnesses that have kept you off work, indoors or in bed?

Yes, No, or Does Not Apply

B. Did you produce phlegm with any of these chest illnesses?

Yes, No, or Does Not Apply

C. In the past year, how many such illnesses with increased phlegm did you have which lasted a week or more?

0-9

16. In the past year have you had any of the following?

*
A. Bronchitis?

Yes or No

Comment:
*
B. Pneumonia (include bronchopneumonia)?

Yes or No

Comment:
*
C. Hay Fever?

Yes or No

Comment:
*
D. Asthma?

Yes or No

Comment:
*
E. Tuberculosis?

Yes or No

Comment:
*
F. Other Allergies?

Yes or No

Comment:
*
G. Chest Surgery?

Yes or No

Comment:
*
H. Other Lung Problems?

Yes or No

Comment:
*
I. Heart Disease?

Yes or No

Comment:
*
J. Frequent Colds?

Yes or No

Comment:
*
K. Chronic Cough?

Yes or No

Comment:
*
L. Shortness of breath when walking or climbing one flight of stairs?

Yes or No

Comment:
*
M. Wheezing?

Yes or No

Comment:
*
N. Cough up phlegm?

Yes or No

Comment:
*
O. Smoke Cigarettes?

Yes or No

Packs per day:
How many years:

Site view: at a glance