**This is to be used in the Post-Offer, Pre-Placement time period.**

Questionnaire Completion Date: [     ]{.underline}

**NOTE:** All employees are asked to complete the Occupational Medicine
Program Termination Interview when they end their employment at the INL.

**NOTE:** This information is for Medical Department use only and when
completed contains Privacy Act Information. It will not be released to
unauthorized persons.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

+---------------------------------+------------------+-----------------+
| Name of Patient: (Last First,   | Date of Birth:   | S Number:       |
| middle)                         |                  |                 |
|                                 |                  |                 |
|                                 |                  |                 |
+---------------------------------+------------------+-----------------+

+-----------------------------------------------------------------------+
| List previous and present medical conditions (hospitalizations, high  |
| blood pressure, cancer, heart disease, etc.) and dates:               |
|                                                                       |
|                                                                       |
+-----------------------------------------------------------------------+

  -------------------- ------------ ------------------ ------------------
  Current Medication   Dosage       Condition treated  Duration
                                    by this medication 

                                                            

                                                            

                                                            

                                                            

                                                            

                                                            

  SYSTEMIC REVIEW- Do                                  
  you have any of the                                  
  following                                            
  -------------------- ------------ ------------------ ------------------

+--------------------------------------------------------+------+------+
| **GENERAL** -                                          | **   | **Y  |
|                                                        | NO** | ES** |
+--------------------------------------------------------+------+------+
| Recent weight change                                   |      |      |
+--------------------------------------------------------+------+------+
| Have you been in good general health most of your      |      |      |
| life?                                                  |      |      |
+--------------------------------------------------------+------+------+
|                                                        |      |      |
+--------------------------------------------------------+------+------+
| **SKIN** -                                             | **   | **Y  |
|                                                        | NO** | ES** |
+--------------------------------------------------------+------+------+
| Jaundice                                               |      |      |
+--------------------------------------------------------+------+------+
| Hives, eczema or rash                                  |      |      |
+--------------------------------------------------------+------+------+
| Frequent infection or boils                            |      |      |
+--------------------------------------------------------+------+------+
| Abnormal pigmentation                                  |      |      |
+--------------------------------------------------------+------+------+
|                                                        |      |      |
+--------------------------------------------------------+------+------+
| **HEAD-EYES-EARS-NOSE-THROAT** -                       | **   | **Y  |
|                                                        | NO** | ES** |
+--------------------------------------------------------+------+------+
| Eye disease or injury                                  |      |      |
+--------------------------------------------------------+------+------+
| Do you wear glasses?                                   |      |      |
+--------------------------------------------------------+------+------+
| Double vision                                          |      |      |
+--------------------------------------------------------+------+------+
| Headaches                                              |      |      |
+--------------------------------------------------------+------+------+
| Glaucoma                                               |      |      |
+--------------------------------------------------------+------+------+
| Itching eyes or nose                                   |      |      |
+--------------------------------------------------------+------+------+
| Sneezing or runny nose                                 |      |      |
+--------------------------------------------------------+------+------+
| Nosebleeds                                             |      |      |
+--------------------------------------------------------+------+------+
| Chronic sinus trouble                                  |      |      |
+--------------------------------------------------------+------+------+
| Ear disease                                            |      |      |
+--------------------------------------------------------+------+------+
| Impaired hearing                                       |      |      |
+--------------------------------------------------------+------+------+
| Dizziness or transient episodes of unconsciousness     |      |      |
+--------------------------------------------------------+------+------+
|                                                        |      |      |
+--------------------------------------------------------+------+------+
| **NECK**                                               | **   | **Y  |
|                                                        | NO** | ES** |
+--------------------------------------------------------+------+------+
| Stiffness                                              |      |      |
+--------------------------------------------------------+------+------+
| Enlarged glands                                        |      |      |
+--------------------------------------------------------+------+------+
|                                                        |      |      |
+--------------------------------------------------------+------+------+
| **RESPIRATORY**                                        | **   | **Y  |
|                                                        | NO** | ES** |
+--------------------------------------------------------+------+------+
| Emphysema                                              |      |      |
+--------------------------------------------------------+------+------+
| Spitting up blood                                      |      |      |
+--------------------------------------------------------+------+------+
| Chronic / frequent cough                               |      |      |
+--------------------------------------------------------+------+------+
| Asthma or wheezing                                     |      |      |
+--------------------------------------------------------+------+------+
| Difficulty breathing                                   |      |      |
+--------------------------------------------------------+------+------+
| Pleurisy or pneumonia                                  |      |      |
+--------------------------------------------------------+------+------+
|                                                        |      |      |
+--------------------------------------------------------+------+------+
| **CARDIOVASCULAR** -                                   | **   | **Y  |
|                                                        | NO** | ES** |
+--------------------------------------------------------+------+------+
| Chest pain or angina pectoris                          |      |      |
+--------------------------------------------------------+------+------+
| Shortness of breath while talking or lying down        |      |      |
+--------------------------------------------------------+------+------+
| **CARDIOVASCULAR -- (Cont.)**                          | **   | **Y  |
|                                                        | NO** | ES** |
+--------------------------------------------------------+------+------+
| Difficulty walking two blocks                          |      |      |
+--------------------------------------------------------+------+------+
| Heart trouble or heart attacks                         |      |      |
+--------------------------------------------------------+------+------+
| High blood pressure                                    |      |      |
+--------------------------------------------------------+------+------+
| Swelling of hands, feet or ankles                      |      |      |
+--------------------------------------------------------+------+------+
| Awakening in the night smothering                      |      |      |
+--------------------------------------------------------+------+------+
|                                                        |      |      |
+--------------------------------------------------------+------+------+
| **GASTROINTESTINAL --**                                | **   | **Y  |
|                                                        | NO** | ES** |
+--------------------------------------------------------+------+------+
| Peptic ulcer                                           |      |      |
+--------------------------------------------------------+------+------+
| Vomiting blood or food                                 |      |      |
+--------------------------------------------------------+------+------+
| Gallbladder disease                                    |      |      |
+--------------------------------------------------------+------+------+
| Liver disease                                          |      |      |
+--------------------------------------------------------+------+------+
| Hepatitis                                              |      |      |
+--------------------------------------------------------+------+------+
| Painful bowel movements                                |      |      |
+--------------------------------------------------------+------+------+
| Black stools                                           |      |      |
+--------------------------------------------------------+------+------+
| Hemorrhoids                                            |      |      |
+--------------------------------------------------------+------+------+
| Recent change in bowel habits                          |      |      |
+--------------------------------------------------------+------+------+
| Frequent diarrhea                                      |      |      |
+--------------------------------------------------------+------+------+
| Heartburn or indigestion                               |      |      |
+--------------------------------------------------------+------+------+
| Cramping or pain in the abdomen                        |      |      |
+--------------------------------------------------------+------+------+
|                                                        |      |      |
+--------------------------------------------------------+------+------+
| **GENITOURINARY**                                      | **   | **Y  |
|                                                        | NO** | ES** |
+--------------------------------------------------------+------+------+
| Frequent urination                                     |      |      |
+--------------------------------------------------------+------+------+
| Recurrent bladder infections                           |      |      |
+--------------------------------------------------------+------+------+
| Burning or painful urination                           |      |      |
+--------------------------------------------------------+------+------+
| Blood in urine                                         |      |      |
+--------------------------------------------------------+------+------+
| Kidney disease                                         |      |      |
+--------------------------------------------------------+------+------+
| Kidney stones                                          |      |      |
+--------------------------------------------------------+------+------+
|                                                        |      |      |
+--------------------------------------------------------+------+------+
| **ALLERGY -**                                          | **   | **Y  |
|                                                        | NO** | ES** |
+--------------------------------------------------------+------+------+
| Any hay fever / environmental allergies                |      |      |
+--------------------------------------------------------+------+------+
|                                                        |      |      |
+--------------------------------------------------------+------+------+
| **LOCOMOTOR-MUSCULOSKELETAL**                          | **   | **Y  |
|                                                        | NO** | ES** |
+--------------------------------------------------------+------+------+
| Varicose veins                                         |      |      |
+--------------------------------------------------------+------+------+
| Difficulty walking                                     |      |      |
+--------------------------------------------------------+------+------+
| Pain in calves caused by walking relieved by rest      |      |      |
+--------------------------------------------------------+------+------+
|                                                        |      |      |
+--------------------------------------------------------+------+------+
| **NEURO-PSYCHIATRIC**                                  | **   | **Y  |
|                                                        | NO** | ES** |
+--------------------------------------------------------+------+------+
| Have you ever had psychiatric care                     |      |      |
+--------------------------------------------------------+------+------+
| Have you been advised to see a psychiatrist            |      |      |
+--------------------------------------------------------+------+------+
| Do you ever have or have you ever had:                 |      |      |
+--------------------------------------------------------+------+------+
| \- Fainting spells                                     |      |      |
+--------------------------------------------------------+------+------+
| \- Convulsions                                         |      |      |
+--------------------------------------------------------+------+------+
| \- Paralysis                                           |      |      |
+--------------------------------------------------------+------+------+
| Heat or cold intolerance                               |      |      |
+--------------------------------------------------------+------+------+
|                                                        |      |      |
+--------------------------------------------------------+------+------+
| **HEMATOLOGIC**                                        | **   | **Y  |
|                                                        | NO** | ES** |
+--------------------------------------------------------+------+------+
| Are you slow to heal after cuts                        |      |      |
+--------------------------------------------------------+------+------+
| **HEMATOLOGIC -- (Cont.)**                             | **   | **Y  |
|                                                        | NO** | ES** |
+--------------------------------------------------------+------+------+
| Blood disease                                          |      |      |
+--------------------------------------------------------+------+------+
| Anemia                                                 |      |      |
+--------------------------------------------------------+------+------+
| Phlebitis                                              |      |      |
+--------------------------------------------------------+------+------+
| Have you had difficulty with bleeding                  |      |      |
|                                                        |      |      |
| excessively after tooth extraction or surgery          |      |      |
+--------------------------------------------------------+------+------+
| Have you had abnormal bruising or bleeding             |      |      |
+--------------------------------------------------------+------+------+
|                                                        |      |      |
+--------------------------------------------------------+------+------+
| **ENDOCRINE**                                          | **   | **Y  |
|                                                        | NO** | ES** |
+--------------------------------------------------------+------+------+
| Thyroid disease                                        |      |      |
+--------------------------------------------------------+------+------+
| Hormone therapy                                        |      |      |
+--------------------------------------------------------+------+------+
| Any change in hair growth                              |      |      |
+--------------------------------------------------------+------+------+

  -----------------------------------------------------------------------
  PAST / CURRENT MEDICAL HISTORY

  -----------------------------------------------------------------------

  -------------------------------------------------------- -------- ---------
  **CHECK EACH ITEM**                                      **NO**   **YES**

  Household contact with anyone with tuberculosis                   

  Tuberculosis or positive TB test                                  

  Wear corrective lenses                                            

  Eye surgery to correct vision                                     

  Lack of vision in either eye                                      

  Eye trouble                                                       

  Hearing loss                                                      

  Recurrent ear infections                                          

  Wear a hearing aid                                                

  Stutter or stammer                                                

  Frequent or severe headaches                                      

  Severe migraines                                                  

  Dizziness or fainting spells                                      

  Head injury                                                       

  Epilepsy or seizure                                               

  Chronic or frequent colds                                         

  Excessive bleeding after injury or dental work                    

  Sinusitis                                                         

  Hay fever or allergic rhinitis                                    

  Asthma                                                            

  Blood in sputum or when coughing                                  

  Chronic cough                                                     

  Palpitation or pounding heart                                     

  Frequent indigestion                                              

  Adverse reaction to medication                                    

  Skin disease, rash or changing mole                               

  Tumor, growth, cyst                                               

  Cancer                                                            

  Hernia                                                            

  Kidney stone or blood in urine                                    

  Sugar or albumin in urine                                         

  Eating disorder (anorexia, bulimia, etc.)                         

  Broken bones                                                      

  Bone, joint or other deformity                                    

  Swollen or painful joints                                         

  Loss of finger or toe                                             

  **CHECK EACH ITEM**                                      **NO**   **YES**

  Painful or "trick" shoulder or elbow                              

  Recurrent back pain or any back injury                            

  Wear a brace or back support                                      

  "Trick" or locked knee                                            

  Foot trouble                                                      

  Plate, pin or rod in any bone                                     

  Nerve injury                                                      

  Cramps in your legs                                               

  Birth defects, inherited disease                                  

  Frequent trouble sleeping                                         

  Sleepwalking                                                      

  Depression or excessive worry                                     

  Suicide attempt or plans                                          

  Anxiety                                                           

  Loss of memory or amnesia                                         

  Nervous trouble of any sort                                       

  Periods of unconsciousness                                        

  Easy fatigability                                                 

  Parent/sibling with diabetes, cancer, stroke or heart             
  disease or high blood pressure                                    

  Diabetes or insulin resistance                                    

  X-ray or other radiation therapy                                  

  Chemotherapy                                                      

  Asbestos or toxic chemical exposure                               

  Been told to cut down or criticized for alcohol use               

  Used illegal substances                                           

  Used tobacco                                                      

  Hair problems                                                     

  Anemia, bleeding disorder, sickle cell                            

  Breast disease                                                    

  Clots, embolism, stroke                                           

  Vericose veins, phlebitis                                         

  Rheumatic fever                                                   

  Scarlet fever                                                     

  Arthritis, rheumatism or bursitis                                 
  -------------------------------------------------------- -------- ---------

  -----------------------------------------------------------------------
  Check Item, if "yes" explain in blank space to right, list explanation
  by item number

  -----------------------------------------------------------------------

<table>
<colgroup>
<col style="width: 8%" />
<col style="width: 37%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 18%" />
<col style="width: 4%" />
<col style="width: 8%" />
<col style="width: 12%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="3">QUESTION</td>
<td colspan="2">YES</td>
<td>NO</td>
<td colspan="4">EXPLANATION</td>
</tr>
<tr class="even">
<td colspan="3"><strong>1</strong>. Have you been refused employment or
been unable to hold a job or stay in school because of:</td>
<td colspan="2"></td>
<td></td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="3">a. Sensitivity to chemicals, dust, sunlight, etc.</td>
<td colspan="2"></td>
<td></td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="3">b. Inability to perform certain motions</td>
<td colspan="2"></td>
<td></td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="3">c. Inability to assume certain positions</td>
<td colspan="2"></td>
<td></td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="3">d. Other medical reasons (if yes, give reasons)</td>
<td colspan="2"></td>
<td></td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="3"><strong>2</strong>. Have you ever been denied life
insurance? (If yes, state reason and give details)</td>
<td colspan="2"></td>
<td></td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="3"><strong>3</strong>. Have you had, or have you been
advised to have, any operation? (If yes, describe and give age at which
this occurred.)</td>
<td colspan="2"></td>
<td></td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="3"><strong>4</strong>. Have you ever been a patient in any
type of hospital? (If yes, specify when, where, why, and name of doctor
and complete address of hospital.)</td>
<td colspan="2"></td>
<td></td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="3"><strong>5</strong>. Have you consulted or been treated
by clinics, physicians, healers, or other practitioners within the last
5 years for other than minor illnesses? (If yes, give complete address
or doctor, hospital, clinic, and details.)</td>
<td colspan="2"></td>
<td></td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="3"><strong>6</strong>. Have you ever been rejected for
military service because of physical, mental, or other reasons? (If yes,
give details and reason for rejection.)</td>
<td colspan="2"></td>
<td></td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="3"><strong>7</strong>. Have you ever been discharged from
military service because of physical, mental, or other reasons? (If yes,
give date, reason, and type of discharge; whether honorable, other than
honorable, for unfitness or unsuitability.)</td>
<td colspan="2"></td>
<td></td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="3"><strong>8</strong>. Have you ever received, is there
pending, or have you ever applied for pension or compensation for
existing disability? (If yes, specify what kind, granted by whom, and
what amount, when, why.)</td>
<td colspan="2"></td>
<td></td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="3"><strong>9.</strong> Have you ever been diagnosed with a
learning disability? (If yes, give type, where, and how diagnosed.)</td>
<td colspan="2"></td>
<td></td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="3"><strong>10.</strong> List travel to underdeveloped
foreign countries including year of travel and duration of stay.</td>
<td colspan="2"></td>
<td></td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="3"><strong>11.</strong> List all past occupations and/or
hobbies which had the possibility of an exposure to hazardous materials
and list the exposure (i.e., chemicals, asbestos, dust, radiation,
etc)</td>
<td colspan="2"></td>
<td></td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="3"><strong>12.</strong> Do you require any work
restrictions or accommodations? (If yes, explain).</td>
<td colspan="2"></td>
<td></td>
<td colspan="4">     </td>
</tr>
<tr class="even">
<td colspan="10">LIST ALL IMMUNIZATIONS RECEIVED:      </td>
</tr>
<tr class="odd">
<td colspan="10">I certify that I have reviewed the foregoing
information supplied by me, and that it is true and complete to the best
of my knowledge. I understand that falsification of information on this
form could result in termination of my employment.</td>
</tr>
<tr class="even">
<td>Signature:</td>
<td colspan="3">     </td>
<td colspan="3">Date:</td>
<td colspan="2">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="10"><ol type="A">
<li><p>May proceed to work assignment, medical requirements are
fulfilled </p></li>
<li><p>Needs to be evaluated by a medical provider </p></li>
</ol></td>
</tr>
<tr class="odd">
<td colspan="2"><p>TYPED OR PRINTED NAME OF PHYSICIAN OR EXAMINER:</p>
<p>     </p></td>
<td colspan="6"><p>SIGNATURE:</p>
<p>     </p></td>
<td colspan="2"><p>DATE:</p>
<p>     </p></td>
</tr>
</tbody>
</table>