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. 38, September 20, 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?

If yes, what kind of problem were you having?

___________________________

2. Have you ever had any kind of operation?

___________________________

If yes, what kind?

___________________________

3. Do you take any kind of medicine regularly?

___________________________

If yes, what kind?

___________________________

4. Are you allergic to any drugs, foods, or chemicals?

___________________________

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?

6. Have you ever been told that you have emphysema, bronchitis, or any other respiratory problems?

7. Have you ever been told that you had hepatitis?

8. Have you ever been told that you had cirrhosis?

9. Have you ever been told that you had cancer?

10. Have you ever had arthritis or joint pain?

11. Have you ever been told that you had high blood pressure?

12. Have you ever had a heart attack or heart trouble?

B-1. Have Medical History Update

1. Have you been in the hospital as a patient any time within the past year?

___________________________

If so, for what condition?

___________________________

2. Have you been under the care of a physician during the past year?

___________________________

If so, for what condition?

___________________________

3. Is there any change in your breathing since last year?

___________________________

Better?

___________________________

Worse?

___________________________

No change?

___________________________

If change, do you know why?

___________________________

4. Is your general health different this year from last year?

___________________________

If different, in what way?

___________________________

5. Have you in the past year or are you now taking any medication on a regular basis?

___________________________

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?

6. Have you ever noticed that any kind of chemical makes you cough?

Wheeze?

Become short of breath or cause your chest to become tight?

7. Are you exposed to any dust or chemicals at home?

___________________________

If yes, explain:

___________________________

___________________________

8. In other jobs, have you ever had exposure to:

Wood dust?

Nickel or chromium?

Silica (foundry, sand blasting)?

Arsenic or asbestos?

Organic solvents?

Urethane foams?

C-1. Occupational History Update

1. Are you working on the same job this year as you were last year?

___________________________

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?

___________________________

If so, explain circumstances:

___________________________

5. Have you noticed that any chemical makes you cough, be short of breath, or wheeze?

___________________________

If so, can you identify it?

___________________________

D. Miscellaneous

1. Do you smoke?

___________________________

If so, how much and for how long?

___________________________

___________________________

Pipe

___________________________

Cigars

___________________________

Cigarettes

2. Do you drink alcohol in any form?

___________________________

If so, how much, how long, and how often?

___________________________

3. Do you wear glasses or contact lenses?

4. Do you get any physical exercise other than that required to do your job?

___________________________

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?

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?

If yes, do you have to rest after climbing several flights of stairs?

If yes, if you walk on the level with people your own age, do you walk slower than they do?

If yes, if you walk slower than a normal pace, do you have to limit the distance that you walk?

If yes, do you have to stop and rest while bathing or dressing?

2. Do you cough as much as three months out of the year?

If yes, have you had this cough for more than two years?

If yes, do you ever cough anything up from chest?

3. Do you ever have a feeling of smothering, unable to take a deep breath, or tightness in you chest?

If yes, do you notice this condition on any particular day of the week?

___________________________

If yes, what day of the week?

If yes, do you notice that this occurs at any particular place?

If yes, do you notice that this is worse after you have returned to work after being off for several days?

4. Have you ever noticed any wheezing in your chest?

If yes, is this only with colds or other infections?

Is this caused by exposure to any kind of dust or other material?

___________________________

If yes, what kind?

5. Have you noticed any burning, tearing, or redness of your eyes when you are at work?

___________________________

If so, explain circumstances:

___________________________

6. Have you noticed any sore or burning throat or itchy or burning nose when you are at work?

___________________________

If so, explain circumstances:

___________________________

7. Have you noticed any stuffiness or dryness of your nose?

8. Do you ever have swelling of the eyelids or face?

9. Have you ever been jaundiced?

If yes, was this accompanied by any pain?

10. Have you ever had a tendency to bruise easily or bleed excessively?

11. Do you have frequent headaches that are not relieved by aspirin or Tylenol?

If yes, do they occur at any particular time of the day or week?

___________________________

If yes, when do they occur?

___________________________

12. Do you have frequent episodes of nervousness or irritability?

13. Do you tend to have trouble concentrating or remembering?

14. Do you ever feel dizzy, light-headed, excessively drowsy or like you have been drugged?

15. Does your vision ever become blurred?

16. Do you have numbness or tingling of the hands or feet or other parts of your body?

17. Have you ever had chronic weakness or fatigue?

18. Have you ever had any swelling of your feet or ankles to the point where you could not wear your shoes?

19. Are you bothered by heartburn or indigestion?

20. Do you ever have itching, dryness, or peeling and scaling of the hands?

21. Do you ever have a burning sensation in the hands or reddening of the skin?

22. Do you ever have cracking or bleeding of the skin on your hands?

23. Are you under a physician's care?

___________________________

If yes, for what are you being treated?

___________________________

24. Do you have any physical complaints today?

___________________________

If yes, explain:

___________________________

25. Do you have other health conditions not covered by these questions?

___________________________

If yes, explain:

___________________________