California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4 - Division of Industrial Safety › Subchapter 7 - General Industry Safety Orders › Group 16 - Control of Hazardous Substances › Article 110 - Regulated Carcinogens › Appendix D to Section 5217 - Nonmandatory Medical Disease Questionnaire

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
A. Identification
___________________________
Plant Name:
___________________________
Date:
___________________________
Employee Name:
___________________________
S.S. #:
___________________________
Job Title:
___________________________
Birthdate:
___________________________
Age:
___________________________
Sex:
___________________________
Height:
___________________________
Weight:
B. Medical History
1. Have you ever been in the hospital as a
						  patient?
Yes []
No []
If yes, what kind of problem were you having?
___________________________
2. Have you ever had any kind of operation?
Yes []
No []
___________________________
If yes, what kind?
___________________________
3. Do you take any kind of medicine regularly?
Yes []
No []
___________________________
If yes, what kind?
___________________________
4. Are you allergic to any drugs, foods, or
						  chemicals?
Yes []
No []
___________________________
If yes, what kind of allergy is it?
___________________________
___________________________
What causes the allergy?
___________________________
5. Have you ever been told that you have asthma,
						  hayfever, or sinusitis?
Yes []
No []
6. Have you ever been told that you have emphysema,
						  bronchitis, or any other respiratory problems?
Yes []
No []
7. Have you ever been told that you had
						  hepatitis?
Yes []
No []
8. Have you ever been told that you had
						  cirrhosis?
Yes []
No []
9. Have you ever been told that you had cancer?
Yes []
No []
10. Have you ever had arthritis or joint pain?
Yes []
No []
11. Have you ever been told that you had high blood
						  pressure?
Yes []
No []
12. Have you ever had a heart attack or heart
						  trouble?
Yes []
No []
B-1. Have Medical History Update
1. Have you been in the hospital as a patient any time
						  within the past year?
Yes []
No []
___________________________
If so, for what condition?
___________________________
2. Have you been under the care of a physician during
						  the past year?
Yes []
No []
___________________________
If so, for what condition?
___________________________
3. Is there any change in your breathing since last
						  year?
Yes []
No []
___________________________
Better?
___________________________
Worse?
___________________________
No change?
___________________________
If change, do you know why?
___________________________
4. Is your general health different this year from last
						  year?
Yes []
No []
___________________________
If different, in what way?
___________________________
5. Have you in the past year or are you now taking any
						  medication on a regular basis?
Yes []
No []
___________________________
Name Rx
___________________________
Condition being treated
C. Occupational History
___________________________
1. How long have you worked for your present
						  employer?
___________________________
___________________________
2. What job have you held with this employer?
Include job title and length in each job.
___________________________
___________________________
___________________________
___________________________
3. In each of these jobs, how many hours a day were you
						  exposed to chemicals?
___________________________
4. What chemicals have you worked with most of the
						  time? _
___________________________
5. Have you ever noticed any type of skin rash you feel
						  was related to your work?
Yes []
No []
6. Have you ever noticed that any kind of chemical
						  makes you cough?
Yes []
No []
Wheeze?
Yes []
No []
Become short of breath or cause your chest to become
						  tight?
Yes []
No []
7. Are you exposed to any dust or chemicals at
						  home?
Yes []
No []
___________________________
If yes, explain:
___________________________
___________________________
8. In other jobs, have you ever had exposure to:
Wood dust?
Yes []
No []
Nickel or chromium?
Yes []
No []
Silica (foundry, sand blasting)?
Yes []
No []
Arsenic or asbestos?
Yes []
No []
Organic solvents?
Yes []
No []
Urethane foams?
Yes []
No []
C-1. Occupational History Update
1. Are you working on the same job this year as you
						  were last year?
Yes []
No []
___________________________
If not, how has your job changed?
___________________________
___________________________
2. What chemicals are you exposed to on your
						  job?
___________________________
___________________________
3. How many hours a day are are exposed to
						  chemicals?
4. Have you noticed any skin rash within the past year
						  you feel was related to your work?
Yes []
No []
___________________________
If so, explain circumstances:
___________________________
5. Have you noticed that any chemical makes you cough,
						  be short of breath, or wheeze?
Yes []
No []
___________________________
If so, can you identify it?
___________________________
D. Miscellaneous
1. Do you smoke?
Yes []
No []
___________________________
If so, how much and for how long?
___________________________
___________________________
Pipe
___________________________
Cigars
___________________________
Cigarettes
2. Do you drink alcohol in any form?
Yes []
No []
___________________________
If so, how much, how long, and how often?
___________________________
3. Do you wear glasses or contact lenses?
Yes []
No []
4. Do you get any physical exercise other than that
						  required to do your job?
Yes []
No []
___________________________
If so, explain:
___________________________
5. Do you have any hobbies or "side jobs" that require
						  you to use chemicals, such as furniture stripping, sand blasting, insulation or
						  manufacture of urethane foam, furniture, etc?
Yes []
No []
If so, please describe, giving type of business or
						  hobby, chemicals used and length of exposures.
___________________________
___________________________
E. Symptoms Questionnaire
1. Do you ever have any shortness of breath?
Yes []
No []
If yes, do you have to rest after climbing several
						  flights of stairs?
Yes []
No []
If yes, if you walk on the level with people your own
						  age, do you walk slower than they do?
Yes []
No []
If yes, if you walk slower than a normal pace, do you
						  have to limit the distance that you walk?
Yes []
No []
If yes, do you have to stop and rest while bathing or
						  dressing?
Yes []
No []
2. Do you cough as much as three months out of the
						  year?
Yes []
No []
If yes, have you had this cough for more than two
						  years?
Yes []
No []
If yes, do you ever cough anything up from
						  chest?
Yes []
No []
3. Do you ever have a feeling of smothering, unable to
						  take a deep breath, or tightness in you chest?
Yes []
No []
If yes, do you notice this condition on any particular
						  day of the week?
Yes []
No []
___________________________
If yes, what day of the week?
If yes, do you notice that this occurs at any
						  particular place?
Yes []
No []
If yes, do you notice that this is worse after you have
						  returned to work after being off for several days?
Yes []
No []
4. Have you ever noticed any wheezing in your
						  chest?
Yes []
No []
If yes, is this only with colds or other
						  infections?
Yes []
No []
Is this caused by exposure to any kind of dust or other
						  material?
Yes []
No []
___________________________
If yes, what kind?
5. Have you noticed any burning, tearing, or redness of
						  your eyes when you are at work?
Yes []
No []
___________________________
If so, explain circumstances:
___________________________
6. Have you noticed any sore or burning throat or itchy
						  or burning nose when you are at work?
Yes []
No []
___________________________
If so, explain circumstances:
___________________________
7. Have you noticed any stuffiness or dryness of your
						  nose?
Yes []
No []
8. Do you ever have swelling of the eyelids or
						  face?
Yes []
No []
9. Have you ever been jaundiced?
Yes []
No []
If yes, was this accompanied by any pain?
Yes []
No []
10. Have you ever had a tendency to bruise easily or
						  bleed excessively?
Yes []
No []
11. Do you have frequent headaches that are not
						  relieved by aspirin or Tylenol?
Yes []
No []
If yes, do they occur at any particular time of the day
						  or week?
Yes []
No []
___________________________
If yes, when do they occur?
___________________________
12. Do you have frequent episodes of nervousness or
						  irritability?
Yes []
No []
13. Do you tend to have trouble concentrating or
						  remembering?
Yes []
No []
14. Do you ever feel dizzy, light-headed, excessively
						  drowsy or like you have been drugged?
Yes []
No []
15. Does your vision ever become blurred?
Yes []
No []
16. Do you have numbness or tingling of the hands or
						  feet or other parts of your body?
Yes []
No []
17. Have you ever had chronic weakness or
						  fatigue?
Yes []
No []
18. Have you ever had any swelling of your feet or
						  ankles to the point where you could not wear your shoes?
Yes []
No []
19. Are you bothered by heartburn or
						  indigestion?
Yes []
No []
20. Do you ever have itching, dryness, or peeling and
						  scaling of the hands?
Yes []
No []
21. Do you ever have a burning sensation in the hands
						  or reddening of the skin?
Yes []
No []
22. Do you ever have cracking or bleeding of the skin
						  on your hands?
Yes []
No []
23. Are you under a physician's care?
Yes []
No []
___________________________
If yes, for what are you being treated?
___________________________
24. Do you have any physical complaints today?
Yes []
No []
___________________________
If yes, explain:
___________________________
25. Do you have other health conditions not covered by
						  these questions?
Yes []
No []
___________________________
If yes, explain:
___________________________