Form Appendix F to 1910 Appendix F to 1910 Medical Questionaires (Non-Mandatory) - 1,3-Butadiene (B

Appendix F to §1910.1051—Medical Questionnaires (Non-Mandatory))

1,3-Butadiene (BD) Initial Health Questionnaire

DIRECTIONS:

You have been asked to answer the questions on this form because you work with BD (butadiene). These questions are about your work, medical history, and health concerns. Please do your best to answer all of the questions. If you need help, please tell the doctor or health care professional who reviews this form.

This form is a confidential medical record. Only information directly related to your health and safety on the job may be given to your employer. Personal health information will not be given to anyone without your consent.

Date: ______________

Name: ___________________ _______________ ____

Last First MI

Job Title: _____________________________________

Company's Name: ______________________________

Supervisor's Name: ____________________ Supervisor's Phone No.: ( ) ____-_____

Work History

1. Please list all jobs you have had in the past, starting with the job you have now and moving back in time to your first job. (For more space, write on the back of this page.)

Main Job Duty	Years	Company Name City, State	Chemicals
1.
2.
3.
4.
5.
6.
7.
8.

2. Please describe what you do during a typical work day. Be sure to tell about you work with BD

______________________________________________________________________

______________________________________________________________________

3. ______________________________________________________________________Please check any of these chemicals that you work with now or have worked with in the past:

benzene ____

glues ____

toluene ____

inks, dyes ____

other solvents, grease cutters ____

insecticides (like DDT, lindane, etc.) ____

paints, varnishes, thinners, strippers ____

dusts ____

carbon tetrachloride ("carbon tet") ____

arsine ____

carbon disulfide ____

lead ____

cement ____

petroleum products ____

nitrites ____

4. Please check the protective clothing or equipment you use at the job you have now:

gloves ____

coveralls ____

respirator ____

dust mask ____

safety glasses, goggles ____

Please circle your answer of yes or no.

5. Does your protective clothing or equipment fit you properly?

yes no

6. Have you ever made changes in your protective clothing or equipment to make it fit better?

yes no

7. Have you been exposed to BD when you were not wearing protective clothing or equipment?

yes no

8. Where do you eat, drink and/or smoke when you are at work?

(Please check all that apply.)

Cafeteria/restaurant/snack bar ____

Break room/employee lounge ____

Smoking lounge ____

At my work station ____

Please circle your answer.

9. Have you been exposed to radiation (like x-rays or nuclear material) at the job you have now or at past jobs?

yes no

10. Do you have any hobbies that expose you to dusts or chemicals (including paints, glues, etc.)?

yes no

11. Do you have any second or side jobs?

yes no

If yes, what are your duties there? __________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

12. Were you in the military?

yes no

If yes, what did you do in the military? ______________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Family Health History

1. In the FAMILY MEMBER column, across from the disease name, write which family member, if any, had the disease.

Disease	Family Member
Cancer
Lymphoma
Sickle Cell Disease or Trait
Immune Disease
Leukemia
Anemia

2. Please fill in the following information about family health:

RELATIVE	ALIVE?	AGE AT DEATH?	CAUSE OF DEATH?
Father
Mother
Brother/Sister
Brother/Sister
Brother/Sister

PERSONAL HEALTH HISTORY

Birth Date ____/____/_____ Age _____ Sex ___ Height ______ Weight _____

Please circle your answer.

1. Do you smoke any tobacco products?

yes no

2. Have you ever had any kind of surgery or operation?

yes no

If yes, what type of surgery: _______________________________________________

______________________________________________________________________

______________________________________________________________________

3. Have you ever been in the hospital for any other reasons?

yes no

If yes, please describe the reason: ___________________________________________

______________________________________________________________________

______________________________________________________________________

4. Do you have any on-going or current medical problems or conditions?

yes no

If yes, please describe: ___________________________________________________

______________________________________________________________________

______________________________________________________________________

5. Do you now have or have you ever had any of the following?

Please check all that apply to you.

unexplained fever ____

anemia ("low blood") ____

HIV/AIDS ____

weakness ____

sickle cell ____

miscarriage ____

skin rash ____

bloody stools ____

leukemia/lymphoma ____

neck mass/swelling ____

wheezing ____

yellowing of skin ____

bruising easily ____

lupus ____

weight loss ____

kidney problems ____

enlarged lymph nodes ____

liver disease ____

cancer ____

infertility ____

drinking problems ____

thyroid problems ____

night sweats ____

chest pain ____

still birth ____

eye redness ____

lumps you can feel ____

child with birth defect ____

autoimmune disease ____

overly tired ____

lung problems ____

rheumatoid arthritis ____

mononucleosis("mono") ____

nagging cough ____

Please circle your answer.

6. Do you have any symptoms or health problems that you think may be related to your work with BD?

yes no

If yes, please describe: ___________________________________________________

______________________________________________________________________

7. Have any of your co-workers had similar symptoms or problems?

yes no don't know

If yes, please describe: ___________________________________________________

______________________________________________________________________

8. Do you notice any irritation of your eyes, nose, throat, lungs or skin when working with BD?

yes no

9. Do you notice any blurred vision, coughing, drowsiness, nausea, or headache when

working with BD?

yes no

10. Do you take any medications (including birth control or over-the-counter)?

yes no

If yes, please list: ________________________________________________________

______________________________________________________________________

11. Are you allergic to any medication, food, or chemicals?

yes no

If yes, please list: ________________________________________________________

______________________________________________________________________

12. Do you have any health conditions not covered by this questionnaire that you think are affected by your work with BD?

yes no

If yes, please explain: ____________________________________________________

______________________________________________________________________

13. Did you understand all the questions?

yes no

_______________________________________

Signature

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