Appendix F to 1910 Medical Questionnaires (Non-Mandatory) 1,3-Butadiene (BD

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

1,3-Butadiene (BD) Update Health Questionnaire

DIRECTIONS:

You have been asked to answer the questions on this form because you work with BD (butadiene). These questions ask about changes in your work, medical history, and health concerns since the last time you were evaluated. 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.: ( ) _____-________

Present Work History

1. Please describe any NEW duties that you have at your job:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Please list any additional job titles you have:

____________________________ _________________________

____________________________ _________________________

____________________________ _________________________

Please circle your answer.

3. Are you exposed to any other chemicals in your work since the last time you were evaluated for exposure to BD?

yes no

If yes, please list what they are: ____________________________________________

______________________________________________________________________

4. Does your personal protective equipment and clothing fit you properly?

yes no

5. Have you made changes in this equipment or clothing to make it fit better?

yes no

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

yes no

7. Are you exposed to any NEW chemicals at home or while working on hobbies?

yes no

If yes, please list what they are: ____________________________________________

______________________________________________________________________

8. Since your last BD health evaluation, have you started working any new second or side jobs?

yes no

If yes, what are your duties there? __________________________________________

______________________________________________________________________

______________________________________________________________________

Personal Health History

1. What is your current weight? ___________ pounds

2. Have you been diagnosed with any new medical conditions or illness since your last

evaluation?

yes no

If yes, please tell what they are: ____________________________________________

______________________________________________________________________

3. Since your last evaluation, have you been in the hospital for any illnesses, injuries, or surgery?

yes no

If yes, please describe: ___________________________________________________

______________________________________________________________________

4. Do you have any of the following? Please place a check for all that apply to you.

unexplained fever ____

anemia ("low blood") ____

HIV/AIDS ____

weakness ____

sickle cell ____

miscarriage ____

skin rash ____

bloody rash ____

leukemia/lymphoma ____

neck mass/swelling ____

wheezing ____

chest pain ____

bruising easily ____

lupus ____

weight loss ____

kidney problems ____

enlarged lymph nodes ____

liver disease ____

cancer ____

infertility ____

drinking problems ____

thyroid problems ____

night sweats ____

still birth ____

eye redness ____

lumps you can feel ____

child with birth defect ____

autoimmune disease ____

overly tired ____

lung problems ____

rheumatoid arthritis ____

mononucleosis "mono" ____

nagging cough ____

yellowing of skin ____

Please circle your answer.

5. 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: ___________________________________________________

______________________________________________________________________

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

yes no don't know

If yes, please describe: ___________________________________________________

______________________________________________________________________

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

BD?

yes no

8. Do you notice any blurred vision, coughing, drowsiness, nausea, or headache when working with BD?

yes no

9. Have you been taking any NEW medications (including birth control or over-the-counter)?

yes no

If yes, please list:

__________________ _________________ ___________________

__________________ _________________ ___________________

10. Have you developed any NEW allergies to medications, foods, or chemicals?

yes no

If yes, please list:

__________________ _________________ ___________________

__________________ _________________ ___________________

11. 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: ____________________________________________________

______________________________________________________________________

12. Did you understand all the questions?

yes no

___________________________________________________________

Signature

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