Medical History and Examination for Pneumoconiosis

U.S. Department of Labor

Medical History and Examination for
Coal Mine Workers' Pneumoconiosis
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Employment Standards Administration
Office of Workers' Compensation Programs
Division of Coal Mine Workers' Compensation

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Note: This report is authorized by law (30 USC 901 et. seq) and required to receive a benefit. The results of this interpretation will aid in
determining the miner's eligibility for black lung benefits. Disclosure of a social security number is voluntary. The failure to disclose such number
will not result in the denial of any right, benefit, or privilege to which the claimant may be entitled. The method of collecting information complies
with the Freedom of Information Act, the Privacy Act of 1974, and OMB Cir. No. 108.
(Please type all responses.)

A. Patient Information
1. Name and Address

2. DOL Claim No.

OMB No.: 1215-0090
Expires: 04-30-05
4. Date of Exam

name:

3. Telephone No.

city:

5. Date of Birth

zip:

state:

7. Examining Physician (name, address, phone no.)

6. Personal Physician (name, address, phone no.)

name:

city:

state:

zip:

zip:
state:
(Please type or neatly print all responses.)

B. Employment History

) is attached. Please review the form and, with the miner's

''Employment History'', Form CM-911a, or equivalent (dated

help, complete only blocks 1.a, below, describing his/her most recent coal mine job (of at least one year's duration). Then, move
on to "C. Patient History''
CM-911a is not attached - complete both sections, 1. and 2., below.
1. Coal Mine Employment - CME. List most recent employment first. In line (a.) describe the last job of at least one year's duration. (Include in
all lines any coal mine construction or transportation work, or work in a mine preparation facility.)
Name of Company
Job Title and Description of Job's Physical Requirements
From
To
a. Last CME held at least one year.

b. Other CME:

years.

c. Additional number of years in CME not described above:

2. Other Employment - Not CME. (If the employment exposed the patient to an occupational toxic inhalant hazard, describe the inhalant under
''Job Title and Description''.)
Name of Company
Job Title and Description
From
To
(mm/yy) (mm/yy)

C. Patient History (Family - Medical - Social)
1. Family History.

(Please type or neatly print all responses.)

Have the patient's parents, children, or other ''blood'' relatives ever had any of the following:
Yes No

Yes

High blood pressure

Asthma

Heart Disease
Tuberculosis

Allergies
Emphysema

Diabetes

Stroke

No

If ''Yes,'' identify family member

Cancer
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Form CM-988
Rev.Jan.1997

C. Patient History (continued)
2. Individual Health/Medical History.

(Please type all responses.)

a. Does the patient have a history of:
Yes

When Manifested

No

Yes No

When Manifested
Arthritis

Frequent Colds
Pneumonia

Heart Disease/Problems

Pleurisy
Attacks of wheezing

Allergies
Cancer (of

Tuberculosis

Diabetes Mellitus

Chronic bronchitis
Bronchial Asthma

High Blood Pressure
Connective Tissue Disease

)

b. Other Significant Conditions or Serious Illnesses (when diagnosed?)

c. Hospitalizations (reasons and dates):

d. Surgery:

3. Social History.
a. Smoking History
Never Smoked

Has Stopped Smoking
; Stopped:

Started:
Smoked what?
How much:

Currently Smoking

1

cigarette(s)

Started:
Smokes what?

per day

How much: 1

cigarette(s)

per month

b. Other Pertinent Social History (e.g. drug or alcohol use; strenuous hobbies):

(Please type or neatly print all responses.)
D. Present Illness/Physical Examination
1. Chief Complaints/Symptoms - as described by patient. Please comment on all ''Yes'' answers (e.g. describe frequency, duration, and/or
severity of symptoms).
Yes

No

Comments
Sputum (daily?)
Wheezing (daily?)
Dyspnea (quantitate)
Cough
Hemoptysis
Chest pain (Inciting Factor):
Orthopnea
Ankle edema
Paroxysmal Nocturnal Dyspnea

(Indicate in D.4., next page, any of the above symptoms manifested during the exam.)
2. Other complaints. (Include here the patient's description of any limitations in physical activities like walking, climbing, and lifting.)

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D. Present Illness/Physical Exam (continued)
3. Current Treatment (including medications):

(Please type all responses.)

4. Physical Findings: Based on Your Physical Examination.
(Show all findings, especially those pertinent to the respiratory system and the cardiovascular system.)
a. Fill in the appropriate data or response:
Thorax & Lungs
Inspection

General

Nose
Membranes

Abdomen
Peristalsis

Obstruction

Tenderness

Weight

Palpation

Discharge
Septum

Ascites
Liver

Temperature

Percussion

Sinuses

Spleen

Pulse
Respiration

Auscultation

Throat

Kidneys
Urinary bladder

B.P. rt. arm

Erythema

Masses

B.P. If. arm
Development

Hernia

Heart

Exudate
Tonsils

Nutrition

Peripheral Pulse

Pharynx

Hydration
Orientation

PMI
Pulsation

Neck

Mentation

Epigastric Cardiac
Pulsation

Height

Masses
Thyroid
Trachea

Personality
Mood

Thrills
Rhythm

Arteries

Extremities
Color

Sounds
Gallop

Veins

Clubbing

Murmurs

Musculoskeletal

Friction rub

Spine
Joints

Edema
Varicosities
Arterial Pulses

Muscles

b. Other relevant findings - narrative summary:

5. Summary of Diagnostic Testing -in the space below, check the applicable block(s) next to any test results (including those conducted in
conjunction with this physical exam) which you reviewed and relied upon, at least in part, to base your medical assessments and
conclusions - especially those on the next page. Be sure to show the date(s) of each test, and summarize the results.

Dates

Summary of Results

Chest X-ray
Vent Study (PFS)
Arterial Blood Gas
Other:
Other:
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D. Present Illness/Physical Exam (Continued)
6. Cardiopulmonary Diagnosis (es): (And provide the basis (as) for your stated diagnosis (es).)

(Please type all responses.)

7. Etiology of Cardiopulmonary Diagnosis (es):(List Primary and Secondary Causes - if applicable - and Provide Rationale.)

8. Impairment - If the patient has chronic respiratory or pulmonary disease, give your medical assessment - With Rationale - of:
a. The degree of severity of the impairment, particularly in terms of the extent to which the impairment prevents the patient from performing his/her
current or last coal mine job of one year's duration: (Refer to section B.1.a. of this form.)

b. The extent to which each of the diagnoses listed in D.6. above contributes to the impairment:

9. Non-Cardiopulmonary Diagnosis -if the patient has any disabling non-respiratory condition(s) indicate what the condition is and
describe its degree of impairment, especially as it may affect the patient's ability to perform his coal mine work:

E. Physician Referral
Should this patient be referred to another physician for further evaluation?
For what reason?

Y

N

Has referral been made?

Y

N

F. Physician Signature
I certify that the information furnished is correct and am aware that my signature attests to its accuracy. I am also aware that any person who willfully makes any false or misleading statement or representation in support of an application for benefits shall be guilty under Title 30 USC 941 of a
misdemeanor and subject to a fine of up to $1,000., or to imprisonment for up to one year, or both.

Signature:

Date:

(Physician's name should be typewritten on front page of this form.)
Public Burden Statement
We estimate that it will take an average of 30 minutes per response to complete this information collection, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. If you have any comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, send them to the Division of Coal Mine Workers' Compensation, U.S. Department of Labor, Room C-3526,
200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE
Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number.

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