Cal. Code Regs. Tit. 8, div. 1, ch. 4, subch. 18, art. 4, app D - Medical Questionnaires Manditory

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This mandatory appendix contains the medical questionnaires that must be administered to all employees who are exposed to asbestos, tremolite, anthophyllite, actinolyte, or a combination of these materials above the permissible exposure limit (0.1 f/cc), and who will therefore be included in their employer's medical surveillance program. Part 1 of the appendix contains the Initial Medical Questionnaire, which must be obtained for all new hires who will be covered by the medical surveillance requirements. Part 2 includes the abbreviated Periodical Medical Questionnaire, which must be administered to all employees who are provided periodic examinations under the medical surveillance provisions of the standard.

Part 1
INITIAL MEDICAL QUESTIONNAIRE

1.	___________________________NAME

2.	SOCIAL SECURITY #	___________________________	___________________________	___________________________	___________________________	___________________________	___________________________	___________________________	___________________________	___________________________
		1	2	3	4	5	6	7	8	9

3.	CLOCK NUMBER				___________________________	___________________________	___________________________	___________________________	___________________________	___________________________
					10	11	12	13	14	15

4.	___________________________PRESENT OCCUPATION

5.	___________________________PLANT

6.	___________________________ADDRESS

7.	___________________________
	(Zip Code)

8.	___________________________TELEPHONE NUMBER

9.	___________________________INTERVIEWER

10.	___________________________DATE				___________________________	___________________________	___________________________	___________________________	___________________________	___________________________
					16	17	18	19	20	21

11.	___________________________Date of Birth				___________________________	___________________________	___________________________	___________________________	___________________________	___________________________
		Month	Day	Year	22	23	24	25	26	27

12.	___________________________Place of Birth

13	Sex	1.	Male	___
		2.	Female	___

14.	What is your marital status?	1.	Single	___	4.	Separated/
		2.	Married	___		Divorced	___
		3.	Widowed	___

15.	Race	1.	White	___	4.	Hispanic	___
		2.	Black	___	5.	Indian	___
		3.	Asian	___	6.	Other	___

16.	___________________________What is the highest grade completed in school?
	(For example 12 years is completion of high school)

OCCUPATIONAL HISTORY

17A.	Have you ever worked full time (30 hours		1. Yes ___ 2. No ___
	per week or more) for 6 months or more?

	IF YES TO 17A:

B.	Have you ever worked for a year or more in		1. Yes ___ 2. No ___
	any dusty job?		3. Does Not Apply ___

	___________________________Specify job/industry		___________________________Total Years Worked

	Was dust exposure:	1. Mild __	2. Moderate __ 3. Severe __

C.	Have you even been exposed to gas or		1. Yes ___ 2. No ___
	chemical fumes in your work?
	___________________________Specify job/industry		___________________________Total Years Worked
	Was exposure:	1. Mild __	2. Moderate __ 3. Severe __

D.	What has been your usual occupation or job--the one you have worked at the longest?

	___________________________1. Job occupation

	___________________________2. Number of years employed in this occupation

	___________________________3. Position/job title

	___________________________4. Business, field or industry

(Record on lines the years in which you have worked in any of these industries. e.g. 1960-1969)

Have you ever worked:

		YES	NO
E.	In a mine? ..........................	[]	[]

F.	In a quarry? ..........................	[]	[]

G.	In a foundry? ..........................	[]	[]

H.	In a pottery? ..........................	[]	[]

I.	In a cotton, flax or hemp mill? ..........................	[]	[]

J.	With asbestos? ..........................	[]	[]

PAST MEDICAL HISTORY

YES

A.	Do you consider yourself to be in good health?			[]	[]

		If "NO" state reason ___________________________

B.	Have you any defect of vision? ..........................			[]	[]

		If "YES" state nature of defect ___________________________

C.	Have you any hearing defect? ..........................			[]	[]

		If "YES" state nature of defect ___________________________

D.	Are you suffering from or have you ever suffered from:

		a.	Epilepsy (or fits, seizures, convulsions)?	[]	[]

		b.	Rheumatic fever?	[]	[]

		c.	Kidney disease?	[]	[]

		d.	Bladder disease?	[]	[]

		e.	Diabetes?	[]	[]

		f.	Jaundice?	[]	[]

19.	CHEST COLDS AND CHEST ILLNESSES

19A.	If you get a cold, does it usually go to your chest? (Usually		1.	Yes ___	2.	No ___
	means more than 1/2 the time)		3.	Don't get colds ___

20A.	During then past 3 years, have you had any chest illnesses		1.	Yes ___	2.	No ___
	that have kept you off work, indoors at home, or in bed?

		IF YES TO 20A
B.	Did you produce phlegm with any of these chest illnesses?		1.	Yes ___	2.	No ___
			3.	Does not apply ___

C.	In the last 3 years, how many such illnesses with (increased)		Number of illnesses ___
	phlegm did you have which lasted a week or more?		No such illnesses ___

21.	Did you have any lung trouble before the age of 16?		1.	Yes ___	2.	No ___

22.	Have you ever had any of the following?

	1A.	Attacks of bronchitis?	1.	Yes ___	2.	No ___

		IF YES TO 1A:
	B.	Was it confirmed by a doctor?	1.	Yes ___	2.	No ___
			3.	Does Not Apply ___

	C.	At what age was your first attack?		Age in Years ___
				Does Not Apply ___

	2A.	Pneumonia (include bronchopneumonia)?	1.	Yes ___	2.	No ___

		IF YES TO 2A:
	B.	Was it confirmed by a doctor?	1.	Yes ___	2.	No ___
			3.	Does Not Apply ___

	C.	At what age did you first have it?		Age in Years ___
				Does Not Apply ___

	3A.	Hay fever?	1.	Yes ___	2.	No ___

		IF YES TO 3A:
	B.	Was it confirmed by a doctor?	1.	Yes ___	2.	No ___
			3.	Does Not Apply ___

	C.	At what age did it start?		Age in Years ___
				Does Not Apply ___

23A.	Have you ever had chronic bronchitis?		1.	Yes ___	2.	No ___

		IF YES TO 23A:
	B.	Do you still have it?	1.	Yes ___	2.	No ___
			3.	Does Not Apply ___

	C.	Was it confirmed by a doctor?	1.	Yes ___	2.	No ___
			3.	Does Not Apply ___

	D.	At what age did it start?		Age in Years ___
				Does Not Apply ___

24A.	Have you ever had emphysema?		1.	Yes ___	2.	No ___

		IF YES TO 24A:
	B.	Do you still have it?	1.	Yes ___	2.	No ___
			3.	Does Not Apply ___

	C.	Was it confirmed by a doctor?	1.	Yes ___	2.	No ___
			3.	Does Not Apply ___

	D.	At what age did it start?		Age in Years ___
				Does Not Apply ___

25A.	Have you ever had asthma?		1.	Yes ___	2.	No ___

		IF YES TO 25A:
	B.	Do you still have it?	1.	Yes ___	2.	No ___
			3.	Does Not Apply ___

	C.	Was it confirmed by a doctor?	1.	Yes ___	2.	No ___
			3.	Does Not Apply ___

	D.	At what age did it start?		Age in Years ___
				Does Not Apply ___

	E.	If you no longer have it, at what age did it stop?		Age stopped ___
				Does Not Apply ___

26.	Have you ever had:
	A.	Any other chest illness?	1.	Yes ___	2.	No ___
		___________________________ If yes, please specify

	B.	Any chest operations?	1.	Yes ___	2.	No ___
		___________________________ If yes, please specify

	C.	Any chest injuries?	1.	Yes ___	2.	No ___
		___________________________ If yes, please specify

27A.	Has a doctor ever told you that you had heart trouble?		1.	Yes ___	2.	No ___

		IF YES TO 27A:
	B.	Have you ever had treatment for heart trouble in the	1.	Yes ___	2.	No ___
		past 10 years?	3.	Does not apply ___

28A.	Has a doctor ever told you that you had high blood pressure?		1.	Yes ___	2.	No ___

		IF YES TO 28A:
	B.	Have you ever had treatment for high blood pressure	1.	Yes ___	2.	No ___
		(hypertension) in the past 10 years?	3.	Does not apply ___

29.	When did you last have your chest X-rayed?	(Year)	___________________________	___________________________	___________________________	___________________________
			25	26	27	28
30.	___________________________Where did you last have your chest X-rayed (if known)?
	___________________________What was the outcome?

FAMILY HISTORY

31.

Were either of your natural parents ever told by a doctor that they had a chronic lung condition such as:

FATHER

MOTHER

Yes

Don't Know

Yes

Don't Know

Chronic

Bronchitis?

___________________________

Emphysema?

___________________________

Asthma?

___________________________

Lung cancer?

___________________________

Other chest conditions?

___________________________

Is parent currently alive?

___________________________

G.	Please Specify	___ Age if Living	___ Age if Living
		___ Age at Death	___ Age at Death
		___ Don't Know	___ Don't Know
H.	Please specify cause of death
	___________________________	___________________________

COUGH

32A.	Do you usually have a cough? (Count a cough with first	1. Yes	___ 2. No	___
	smoke or on first going out of doors. Exclude clearing of throat.) [If no, skip to question 32C.]

B.	Do you usually cough as much as 4 to 6 times a day	1. Yes	___ 2. No	___
	4 or more days out of the week?

C.	Do you usually cough at all on getting up or first thing in	1. Yes	___ 2. No	___
	the morning?

D.	Do you usually cough at all during the rest of the day	1. Yes	___ 2. No	___
	or at night?

IF YES TO ANY OF ABOVE (32A, B, C, OR D), ANSWER THE FOLLOWING. IF NO TO ALL, CHECK DOES NOT APPLY AND SKIP TO NEXT PAGE.

E.	Do you usually cough like this on most days for 3	1. Yes	___ 2. No	___
	consecutive months or more during the year?	3. Does not apply		___

F.	For how many years have you had the cough?	Number of Years		___
		Does Not Apply		___

33A.	Do you usually bring up phlegm from your chest?	1. Yes	___ 2. No	___
	(Count phlegm with the first smoke or on first going out of doors. Exclude phlegm from the nose. Count swallowed phlegm.) (If no, skip to 33C)

B.	Do you usually bring up phlegm like this as much	1. Yes	___ 2. No	___
	as twice a day 4 or more days out of the week?

C.	Do you usually bring up phlegm at all on getting	1. Yes	___ 2. No	___
	up or first thing in the morning?

D.	Do you usually bring up phlegm at all during	1. Yes	___ 2. No	___
	the rest of the day or at night?

IF YES TO ANY OF THE ABOVE (33A, B, C, OR D), ANSWER THE FOLLOWING: IF NO TO ALL, CHECK DOES NOT APPLY AND SKIP TO 34A.

E.	Do you bring up phlegm like this on most days	1. Yes	___ 2. No	___
	for 3 consecutive months or more during the year?	3. Does not apply		___

F.	For how many years have you had trouble with phlegm?	Number of Years		___
		Does Not apply		___

EPISODES OF COUGH AND PHLEGM

34A.	Have you had periods or episodes of (increased*) cough	1. Yes	___ 2. No	___
	and phlegm lasting for 3 weeks or more each year?
	*(For persons who usually have cough and/or phlegm)

	IF YES TO 34A

B.	For how long have you had at least 1 such episode per year?	Number of Years		___
		Does Not apply		___

WHEEZING

35A.	Does you chest ever sound wheezy or whistling
	1. When you have a cold?	1. Yes	___ 2. No	___
	2. Occasionally apart from colds?	1. Yes	___ 2. No	___
	3. Most days or nights?	1. Yes	___ 2. No	___

	IF YES TO 1, 2, or 3 in 35A

B.	For how many years has this been present?	Number of Years		___
		Does Not apply		___

36A.	Have you ever had an attack of wheezing that has made you	1. Yes	___ 2. No	___
	feel short of breath?

B.	How old were you when you had your first such attack?	Age in years		___
		Does not apply		___

C.	Have you had 2 or more such episodes?	1. Yes	___ 2. No	___
		3. Does not apply		___

D.	Have you ever required medicine or treatment	1. Yes	___ 2. No	___
	for the(se) attack(s)?	3. Does not apply		___

BREATHLESSNESS

37.	If disabled from walking by any condition other than heart or lung disease, please describe and proceed to question 39A.
	___________________________Nature of condition(s)

38A.	Are you troubled by shortness of breath when	1. Yes	___ 2. No	___
	hurrying on the level or walking up a slight hill?

	IF YES TO 38A

B.	Do you have a walk slower than people of your age	1. Yes	___ 2. No	___
	on the level because of breathlessness?	3. Does not apply		___

C.	Do you ever have to stop for breath when walking at	1. Yes	___ 2. No	___
	your own pace on the level?	3. Does not apply		___

D.	Do you ever have to stop for breath after walking	1. Yes	___ 2. No	___
	about 100 yards (or after a few minutes) on the level?	3. Does not apply		___

E.	Are you too breathless to leave the house or	1. Yes	___ 2. No	___
	breathless on dressing or climbing one flight of stairs?	3. Does not apply		___

TOBACCO SMOKING

39A.	Have you ever smoked cigarettes? (No means less than 20	1. Yes	___ 2. No	___
	packs of cigarettes or 12 oz. of tobacco in a lifetime or less than 1 cigarette a day for 1 year.)

	IF YES TO 39A

B.	Do you now smoke cigarettes (as of one month ago)	1. Yes	___ 2. No	___
		3. Does not apply		___

C.	How old were you when you first started regular	Age in years		___
	cigarette smoking?	Does not apply		___

D.	If you have stopped smoking cigarettes completely,	Age stopped		___
	how old were you when you stopped?	Check if still smoking		___
		Does not apply		___

E.	How many cigarettes do you smoke per day now?	Cigarettes per day		___
		Does not apply		___

F.	On the average of the entire time you smoked, how	Cigarettes per day		___
	many cigarettes did you smoke per day?	Does not apply		___

G.	Do or did you inhale the cigarette smoke?	1. Does not apply		___
		2. Not at all		___
		3. Slightly		___
		4. Moderately		___
		5. Deeply		___

40A.	Have you ever smoked a pipe regularly?	1. Yes	___ 2. No	___
	(Yes means more than 12 oz. of tobacco in a lifetime.)

	IF YES TO 40A:

B.	1. How old wer e you when you started to smoke a pipe regularly?	Age		___

	2. If you have stopped smoking a pipe completely, how old were	Age stopped		___
	you when you stopped?	Check of still smoking pipe		___
		Does not apply		___

C.	On the average over the entire time you smoked a pipe, how much pipe tobacco did you smoke per week?	___ oz. per week (a standard pouch of tobacco contains 1 1/2 oz.)
		___ Does not apply

D.	How much pipe tobacco are you smoking now?	oz. per week		___
		Not currently smoking a pipe		___

E.	Do you or did you inhale the pipe smoke?	1. Never smoked		___
		2. Not at all		___
		3. Slightly		___
		4. Moderately		___
		5. Deeply		___

41A.	Have you ever smoked cigars regularly?	1. Yes	___ 2. No	___
	(Yes means more than 1 cigar a week for a year)

	IF YES TO 41A

FOR PERSONS WHO HAVE EVER SMOKED CIGARS

B.	1. How old were you when you started smoking cigars regularly?	Age	___

	2. If you have stopped smoking cigars completely, how old were	Age stopped	___
	you when you stopped?	Check if still smoking cigars	___
		Does not apply	___

C.	On the average over the entire time you smoked cigars,	Cigars per week	___
	how many cigars did you smoke per week?	Does not apply	___

D.	How many cigars are you smoking per week now?	Cigars per week	___
		Check if not smoking cigars currently	___

E.	Do or did you inhale the cigar smoke?	1. Never smoked	___
		2. Not at all	___
		3. Slightly	___
		4. Moderately	___
		5. Deeply	___

___________________________Signature

___________________________Date

Part 2
PERIODIC MEDICAL QUESTIONNAIRE

1.	___________________________NAME

2.	SOCIAL SECURITY #	___________________________	___________________________	___________________________	___________________________	___________________________	___________________________	___________________________	___________________________	___________________________
		1	2	3	4	5	6	7	8	9

3.	CLOCK NUMBER				___________________________	___________________________	___________________________	___________________________	___________________________	___________________________
					10	11	12	13	14	15

4.	___________________________PRESENT OCCUPATION

5.	___________________________PLANT

6.	___________________________ADDRESS

7.	___________________________
	(Zip Code)

8.	___________________________TELEPHONE NUMBER

9.	___________________________INTERVIEWER

10.	___________________________DATE				___________________________	___________________________	___________________________	___________________________	___________________________	___________________________
					16	17	18	19	20	21

11.	What is your marital status?	1.	Single	___	4.	Separated/
		2.	Married	___		Divorced	___
		3.	Widowed	___

12.	OCCUPATIONAL HISTORY

12A.	In the past year, did you work full time (30 hours	1. Yes	___ 2. No	___
	per week or more) for 6 months or more?

	IF YES TO 12A:

12B.	In the past year, did you work in a dusty job?	1. Yes	___ 2. No	___
		3. Does not apply		___

12C.	Was dust exposure:	1. Mild ___		2. Moderate___	3. Severe___

12D.	In the past year, were you exposed to gas or	1. Yes	___ 2. No	___
	chemical fumes in your work?

12E.	Was exposure:	1. Mild ___		2. Moderate ___	3. Severe___

12F.	In the past year,
	what was your:	1. Job/occupation?___________________________
		2. Position/job title? ___________________________

13.	RECENT MEDICAL HISTORY

13A.	Do you consider yourself to be in good heath?	Yes ___ No ___

	___________________________IF NO, state reason

13B.	In the past year, have you developed:		Yes	No
		Epilepsy?	___	___
		Rheumatic fever?	___	___
		Kidney disease?	___	___
		Bladder disease?	___	___
		Diabetes?	___	___
		Jaundice?	___	___
		Cancer?	___	___

14.	CHEST COLDS AND CHEST ILLNESSES

14A.	If you get a cold, does it usually go to your chest?
	(Usually means more than 1/2 the time)
		1. Yes	___ 2 No.	___
		3. Don't get colds	___

15A.	During the past year, have you had any chest illnesses	1. Yes	___ 2 No.	___
	that have kept you off work, indoors at home, or in bed?	3. Does Not Apply	___

	IF YES TO 15A:

15B.	Did you produce phlegm with any of these chest illnesses?	1. Yes	___ 2 No.	___
		3. Does Not Apply	___

15C.	In the past year, how many such illnesses with (increased)	Number of illnesses	___
	phlegm did you have which lasted a week or more?	No such illnesses	___

16.	RESPIRATORY SYSTEM

In the past year have you had:
	Yes or No	Further Comment on Positive Answers
Asthma	___

Bronchitis	___

Hay Fever	___

Other Allergies	___

	Yes or No	Further Comment on Positive Answers
Pneumonia	___

Tuberculosis	___

Chest Surgery	___

Other Lung Problems	___

Heart Disease	___

Do you have:

	Yes or No	Further Comment on Positive Answers
Frequent colds	___

Chronic cough	___

Shortness of breath when walking or climbing one flight of stairs	___

Do you:

Wheeze	___

Cough up phlegm	___

Smoke cigarettes	___	Packs per day ___ How many years ___

___________________________Date

___________________________Signature

Notes

Cal. Code Regs. Tit. 8, div. 1, ch. 4, subch. 18, art. 4, app D

1. Editorial correction of Part 1, No. 16 (Register 99, No. 28).

Note: Authority cited: Section 142.3, Labor Code. Reference: Section 142.3, Labor Code.

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