Form Ars 182C PDF Details

The Ars 182C form stands as a critical instrument under the umbrella of the Occupational Medical Surveillance Program, aimed at collecting comprehensive health information from individuals in the context of their workplace environment. Embedded within its structure are sections that meticulously gather demographic details, employment history, and assess aspects of lifestyle that could influence occupational health, such as recreational and smoking histories. Furthermore, the form delves into personal medical history spanning various systems including cardiovascular, digestive, respiratory, and endocrine, among others. Additionally, it looks into the subject's exposure to potential occupational hazards, which could encompass a wide range of chemical and physical agents, underlining the importance of this document in identifying and mitigating workplace health risks. Such detailed surveillance plays a pivotal role not just in safeguarding the health and well-being of employees, but also in enabling a healthy work environment conducive to productivity and safety. As such, the Ars 182C form is more than just a questionnaire; it is a comprehensive tool designed to capture a holistic view of an employee's health in relation to their work, thereby fostering the foundation for preventive measures in occupational health.

QuestionAnswer
Form NameForm Ars 182C
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namesVIOUSLY, fillable ars 182, ars 182c fillable, Mantoux

Form Preview Example

 

OCCUPATIONAL MEDICAL SURVEILLANCE PROGRAM

 

OCCUPATIONAL/MEDICAL QUESTIONNAIRE

 

(See Form ARS-182A/B for Privacy Act Notification)

 

 

 

 

 

DEMOGRAPHIC INFORMATION

 

LAST NAME

FIRST NAME

MIDDLE NAME

 

 

 

SOCIAL SECURITY NUMBER

DATE OF BIRTH (mm/dd/yyyy)

SEX

MALE

FEMALE

RACE

BLACK/NOT HISPANIC ORIGIN

WHITE/NOT HISPANIC ORIGIN

HISPANIC

AMERICAN INDIAN/ ALASKAN NATIVE

OTHER (specify):

MARITAL STATUS

SINGLE/NEVER MARRIED

MARRIED/LIVING TOGETHER

SEPARATED

DIVORCED

WIDOWED

ASIAN/PACIFIC ISLANDER

EMPLOYEE'S MAILING ADDRESS (WHERE CONFIDENTIAL MAIL CAN BE DELIVERED)

STREET

CITY

APARTMENT NO.

STATE

ZIP CODE

 

 

EMPLOYEE'S PHYSICIAN

LAST NAME

STREET ADDRESS

CITY

OFFICE TELEPHONE (Include Area Code)

SUITE NO.

STATE

ZIP CODE

 

 

EMPLOYEE'S CURRENT JOB

LOCATION (City)

STATE

ZIP CODE

 

 

 

REGULAR WORKPLACE (Building and Room No.)

 

GS SERIES

 

 

 

JOB TITLE

 

YEARS IN PRESENT JOB

 

 

 

 

Have you ever been a resident outside the United States?

No

Yes

 

 

 

 

 

 

 

 

If yes, please list the location(s) and date(s).

 

 

FROM

TO

 

 

 

MONTH/YEAR

MONTH/YEAR

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

3.

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

 

6.

 

 

 

 

 

 

 

 

 

 

Form ARS-182C (11/2000)

USDA-ARS

This form was electronically produced by USDA/ARS/ITD using INFORMS

Previous edition not usable

 

 

SOCIAL SECURITY NO.

EMPLOYMENT HISTORY

Start with the job you held before this one, and list all the jobs you ever had. Include military service and any part-time jobs.

COMPANY NAME OR TYPE OF BUSINESS

FROM

TO

MONTH/YEAR

MONTH/YEAR

 

 

JOB TITLE OR DESCRIPTION

Form ARS-182C (11/2000) (page

USDA-ARS

This form was electronically produced by USDA/ARS/ITD using INFORMS

2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY NO.

 

 

 

 

 

 

 

OCCUPATIONAL MEDICAL SURVEILLANCE PROGRAM

 

 

 

 

 

 

 

 

 

 

 

 

RECREATIONAL HISTORY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Please print)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you now or have you in the past, done any of the following as a hobby or

Do you now or have you in the past, come into contact with any of the following

 

during your spare time?

 

 

 

 

 

 

during your spare time?

 

 

 

 

 

 

 

 

 

 

 

 

PRE-

 

CUR-

 

 

PRE-

 

 

CUR-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

VIOUSLY

 

RENTLY

 

 

 

 

NO

 

VIOUSLY

 

RENTLY

 

Auto mechanic work

 

 

 

 

 

 

Acids

 

 

 

 

 

 

 

 

 

Auto body work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bonding agents or industrial glues

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Been exposed to rubber cement for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cleaning fluids

 

 

 

 

 

 

 

 

 

extended periods of time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fertilizers

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Carpentry

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gasoline or other petroleum products

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ceramics

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Herbicides or weed killers

 

 

 

 

 

 

 

 

 

Etching/metal work/jewelry/metal sculpture

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insecticides/pesticides

 

 

 

 

 

 

 

 

 

Furniture refinishing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

House painting

 

 

 

 

 

 

Insulation material

 

 

 

 

 

 

 

 

 

Lawn/Garden maintenance or farming

 

 

 

 

 

 

Lacquer, varnish or enamel paints

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Make your own cartridges/salvage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Leather dyes

 

 

 

 

 

 

 

 

 

spent cartridges

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Paint thinners and removers

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Make your own fishing sinkers

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Soldering agents

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Oil painting

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Solvents/degreasers

 

 

 

 

 

 

 

 

 

Pottery

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wood stains

 

 

 

 

 

 

 

 

 

Recreational hunting/shooting

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In your work are you now or have you been exposed to any of the following agents?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRE-

 

 

 

 

 

 

 

PRE-

 

 

 

 

 

 

PRE-

 

 

 

 

SENT

PAST

 

 

 

 

 

SENT

PAST

 

 

 

 

 

SENT

 

PAST

 

Inorganic flourides

 

 

 

 

Excessive noise

 

 

 

Asbestos

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lead

 

 

 

 

Nitrogen oxides

 

 

 

Suspect or known carcinogens

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Benzene

 

 

 

 

Crystalline silica

 

 

 

Pesticides

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Coke oven emissions

 

 

 

 

Nitric acid

 

 

 

 

Bacteria or viruses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Inorganic arsenic

 

 

 

 

Ammonia

 

 

 

 

Primate animals

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Methylene chloride

 

 

 

 

Beryllium

 

 

 

 

Vibrating tools

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vinyl chloride

 

 

 

 

Phosgene

 

 

 

 

Radiation (Ionizing)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Toluene diisocyanate

 

 

 

 

Allyl chloride

 

 

 

 

Radiation (Non-Ionizing)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please make a list of those substances that you handle in your work. Star (*) those that particularly concern you from a health standpoint.

Indicate any symptoms that you have experienced that might be due to exposure at work and indicate the suspected cause.

SYMPTOM:

CAUSE:

Have you experienced any job related illnesses or injuries since being employed by the USDA?

IF YES, GIVE DETAILS:

No

Yes

MONTH AND YEAR:

Form ARS-182C (11/2000) (page 3)

USDA-ARS

This form was electronically produced by USDA/ARS/ITD using INFORMS

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY NO.

 

 

 

 

 

 

 

OCCUPATIONAL MEDICAL SURVEILLANCE PROGRAM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SMOKING HISTORY

 

 

 

 

 

 

LIFE-STYLE HISTORY

 

 

 

 

 

 

 

 

 

 

 

 

CIGARETTES: Have you ever smoked cigarettes regularly?

 

 

 

ALCOHOLIC BEVERAGES: Do you now or have you ever drunk alcoholic

 

No

Yes

(If yes, please answer the following questions.)

beverages (such as wine, beer, or hard liquor) regularly?

 

 

 

 

(If yes, please answer the following questions.)

 

 

("No" means never

a.

How old were you when you

 

 

 

No

Yes

 

 

smoked, or smoked less

 

started smoking cigarettes

 

Years

 

 

a.

Which of the following do you

 

 

than 20 packs of

 

 

regularly?

 

 

 

 

regularly drink? (Check all that

 

 

 

 

 

 

 

 

 

 

 

 

cigarettes or 12 ozs. of

 

 

 

 

 

 

 

 

apply.)

 

 

 

Wine

 

 

b.

Do you still smoke cigarettes?

 

 

 

 

 

 

 

 

 

 

 

 

 

tobacco in life-time, or

No

Yes

 

 

 

 

 

 

 

Beer

 

 

 

If yes, how many cigarettes do

 

 

 

 

 

 

 

 

 

less than 1 cigarette a

 

 

Cig./da

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

day for one year.)

 

you now smoke per day?

 

 

 

 

 

 

 

 

Liquor

 

 

 

c.

If you have stopped smoking

 

 

 

 

 

b. Have you stopped drinking

 

 

No

Yes

 

 

 

 

cigarettes, how old were you

 

Years

 

 

 

regularly?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

when you stopped?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d.

On the average, of the entire

 

 

 

 

 

 

If yes, how many years ago did

 

 

Years

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

you stop?

 

 

 

 

 

 

 

 

 

 

time you have smoked, how

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

How much do (did) you drink

on

 

 

 

 

 

many cigarettes did you smoke

 

 

 

 

 

 

 

 

 

 

 

Cig./da

 

 

 

an average day or in an average

 

 

 

 

 

per day?

 

 

 

 

 

 

 

 

 

 

 

 

 

week?

 

 

 

 

 

 

 

 

 

e.

Do, or did you inhale the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

cigarette smoke?

No

Yes

 

 

 

Less than 1 drink per day, or less

 

 

 

 

 

 

 

 

 

 

 

 

than 7 drinks per week.

 

 

 

 

 

 

PIPES: Have you ever smoked a pipe regularly?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

Yes

(If yes, please answer the following questions.)

 

 

 

1 to 2 drinks per day, or 7 to 17

 

 

 

 

 

drinks per week.

 

 

 

 

 

 

 

("No" means never

a.

How old were you when you

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

smoked, or smoked no

 

started smoking pipes regularly?

 

Years

 

 

 

3 to 4 drinks per day, or 18 to 31

 

 

more than 12 ozs. of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

drinks per week.

 

 

 

 

 

 

 

pipe tobacco in your

b.

Do you still smoke pipes?

No

Yes

 

 

 

 

 

 

 

 

 

 

life-time.)

 

 

If yes, how many ounces of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

pipe tobacco do you now

 

Ozs./week

 

 

 

5 or more drinks per day, or more

 

 

 

 

 

 

 

 

 

 

 

 

 

 

smoke per week?

 

 

 

 

than 31 drinks per week.

 

 

 

 

 

 

 

 

c.

If you have stopped smoking

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a pipe, how old were you

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Years

EXERCISE: Do you get exercise on a regular basis?

 

 

 

 

 

 

 

 

 

when you stopped?

 

 

 

 

 

 

 

 

 

d.

On the average, of the entire

 

 

 

No

Yes

(If yes, please answer the following questions.)

 

 

 

 

 

time you have smoked, how

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

many ounces of tobacco did

 

Ozs./week

 

 

a.

How many days per week?

 

 

 

 

Days/week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

you smoke per day?

 

 

 

b.

How many minutes do you

 

 

 

 

 

 

 

 

e.

Do, or did you inhale the pipe

 

 

 

 

 

 

 

 

 

 

 

 

 

 

smoke?

No

Yes

 

 

 

exercise?

 

 

 

 

 

Minutes

 

CIGARS: Have you ever smoked cigars regularly?

 

 

 

 

 

c. Describe the kind of

 

 

 

 

 

 

 

No

Yes

(If yes, please answer the following questions.)

 

 

exercise

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

you get:

 

 

 

 

 

 

 

("No" means never

a. How old were you when you

 

 

 

 

 

 

 

 

 

 

 

 

 

smoked, or smoked

 

started smoking cigars

 

Years

 

 

 

 

 

 

 

 

 

 

 

 

regularly?

 

 

 

 

 

 

 

 

 

 

 

 

no more than 1 cigar

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a week for 1 entire

b. Do you still smoke cigars?

No

Yes

 

 

 

 

 

 

 

 

 

 

 

year.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, how many cigars do

 

Cigars/day

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

you now smoke per day?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. If you have stopped smoking

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

cigars, how old were you

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

when you stopped?

 

Years

DIET:

 

 

 

 

 

 

 

 

 

 

 

 

d. On the average, of the entire

 

 

 

 

 

a. Do you drink more than two

 

 

 

 

 

 

 

 

 

time you have smoked

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

cups of coffee or tea a day?

 

 

No

Yes

 

 

 

 

cigars, how many cigars did

 

Cigars/day

 

 

 

 

 

 

 

 

 

you smoke per day?

 

 

 

b. Do you restrict your diet?

 

 

 

 

 

 

 

 

e. Do, or did you inhale the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If yes, which of the following

 

 

 

 

 

 

 

 

 

cigar smoke?

No

Yes

 

 

 

items do you restrict?)

 

 

 

No

Yes

 

TOBACCO CHEWING: Have you ever chewed tobacco regularly?

 

 

 

 

 

 

 

 

 

 

 

 

 

No

Yes

(If yes, please answer the following questions.)

 

 

 

Meat

Sodium or Salt

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

How old were you when you

 

 

 

 

 

 

Sugar

Foods high in cholesterol

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

started chewing tobacco

 

Years

 

 

 

Other (describe):

 

 

 

 

 

 

 

 

 

 

regularly?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

Do you still chew tobacco?

No

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

c.

If you have stopped chewing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

tobacco, how old were you

 

Years

 

 

 

 

 

 

 

 

 

 

 

 

 

 

when you stopped?

 

 

 

c. How many years have you been

 

 

 

Years

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

restricting your diet?

 

 

 

 

 

 

SNUFF: Have you ever used snuff regularly?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Why are you restricting your diet?

 

 

 

 

(If yes, please answer the following questions.)

 

 

 

 

No

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Religious

Medical

 

 

 

 

a.

How old were you when you

 

 

 

 

 

 

reasons

reasons

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

started using snuff regularly?

 

Years

 

 

 

Other (describe):

 

 

 

 

 

 

 

 

 

b.

Do you still use snuff?

No

Yes

 

 

 

 

 

 

 

 

 

 

c.If you have stopped using

snuff, how old were you

 

 

Years

when you stopped?

 

 

Form ARS-182C (11/2000) (page 4)

USDA-ARS

This form was electronically produced by USDA/ARS/ITD using INFORMS

SOCIAL SECURITY NO.

OCCUPATIONAL MEDICAL SURVEILLANCE PROGRAM

MEDICAL HISTORY

 

CARDIOVASCULAR: Have you ever had or do you now have any of the following

DIGESTIVE SYSTEM: Have you ever had or do you now have any of the following

 

 

 

 

 

 

 

 

 

 

 

illnesses or problems with your heart or blood vessels?

 

YES

YES

illnesses or problems with your digestive system?

 

 

YES

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

PAST

CURRENT

 

 

NO

 

PAST

CURRENT

 

 

Heart Attack

 

 

 

 

 

Blood in stool

 

 

 

 

 

 

Angina Pectoris

 

 

 

 

 

Stomach or Duodenal Ulcer

 

 

 

 

 

 

Heart Murmur

 

 

 

 

 

Appendicitis

 

 

 

 

 

 

Enlarged Heart

 

 

 

 

 

Nervous stomach

 

 

 

 

 

 

Stroke

 

 

 

 

 

Colitis

 

 

 

 

 

 

High Blood Pressure

 

 

 

 

 

Frequent constipation

 

 

 

 

 

 

Other problems with blood pressure

 

 

 

 

 

Frequent diarrhea

 

 

 

 

 

 

Episodes of chest pains, tightness, discomfort

 

 

 

 

 

Frequent indigestion

 

 

 

 

 

 

Rheumatic Heart Disease

 

 

 

 

 

Stomach pain

 

 

 

 

 

 

Arteriosclerosis

 

 

 

 

 

Hiatal hernia or rupture

 

 

 

 

 

 

Varicose Veins

 

 

 

 

 

Diverticulitis

 

 

 

 

 

 

Other (specify):

 

 

 

 

 

Hemorrhoids or piles

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (specify):

 

 

 

 

 

 

 

Have you ever had heart surgery? (If yes,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

system?

 

 

 

 

 

RESPIRATORY ILLNESS/CONDITIONS: Have you had or do you now have any

(If yes, describe):

 

 

 

 

 

 

 

 

of the following illnesses or problems with your lungs?

 

 

 

YES

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

PAST

CURRENT

 

 

 

 

 

 

 

 

Frequent Colds

 

 

 

 

 

 

 

 

 

 

 

 

 

Coughed up Blood

 

 

 

 

 

LIVER AND SPLEEN: Have you ever or do you now have any of the following

 

 

 

 

 

 

 

 

 

illnesses or problems with your liver, spleen, or gallbladder?

 

 

 

 

 

 

Chronic Cough

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lung or Breathing difficulties or Shortness of Breath

 

 

 

 

 

NO

 

PAST

CURRENT

 

 

 

 

 

 

 

 

 

Cirrhosis of the liver

 

 

 

 

 

 

Asthma

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hepatitis

 

 

 

 

 

 

Emphysema

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Jaundice

 

 

 

 

 

 

Pneumonia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gallbladder disease

 

 

 

 

 

 

Tuberculosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gallbladder stones

 

 

 

 

 

 

Bronchitis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Injury to your spleen

 

 

 

 

 

 

Pleurisy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (specify):

 

 

 

 

 

 

Other (specify):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever had surgery on your lungs?

 

 

 

 

 

 

 

 

 

 

 

 

 

(If yes, describe):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever had surgery on your liver or spleen?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If yes, describe):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever had or do you now have any of the following problems with your

 

 

 

 

 

 

 

 

 

mouth, nose or throat?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

YES

 

 

 

 

 

 

 

 

 

 

 

 

NO

PAST

CURRENT

KIDNEYS/URINARY TRACT: Have you ever had or do you now have any of the

 

 

Nasal passages frequently irritated

 

 

 

 

 

following illnesses or problems with your kidneys or urinary tract?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

YES

 

 

Nose Bleeds often

 

 

 

 

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

PAST

CURRENT

 

 

Throat is often irritated

 

 

 

 

 

Blood in urine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Voice is hoarse when you do not have a cold

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pain or burning when urinating

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mouth/Gums frequently have sores/ulcers

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Kidney disease

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gums shrinking, irritated or bleeding

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Kidney infection

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (specify):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Kidney stones

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nephritis (Bright's Disease)

 

 

 

 

 

ENDOCRINE: Have you ever had or do you now have any of the following

 

 

 

Bladder Infection

 

 

 

 

 

illnesses or conditions?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

YES

Prostate gland enlargement/infection (Males only)

 

 

 

 

 

 

 

 

 

 

NO

PAST

CURRENT

 

 

 

 

 

 

Hypoglycemia

 

 

Tumor in urinary tract

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (specify):

 

 

 

 

 

 

 

Diabetes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Goiter

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Thyroid disease or disorder

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Swollen glands or nodes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever had surgery on your kidneys or urinary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pancreatitis

 

 

 

 

 

tract? (If yes, describe):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other gland problems (specify):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form ARS-182C (11/2000) (page 5)

USDA-ARS

 

 

This form was electronically produced by USDA/ARS/ITD using INFORMS

SOCIAL SECURITY NO.

OCCUPATIONAL MEDICAL SURVEILLANCE PROGRAM

MEDICAL HISTORY (Continued)

REPRODUCTIVE HISTORY (please answer all four questions):

 

 

 

BONES AND JOINTS: Have you ever had or do you now have any of the

a. Have you or your partner ever had a problem conceiving a child?

Yes

 

No

following problems with your bones or joints?

 

YES

YES

 

 

 

 

 

 

 

Previou

 

 

 

 

 

NO

PAST

CURRENT

 

 

 

 

 

 

Present

 

 

 

Arthritis or Rheumatism

 

 

 

 

 

 

 

If yes,

Self

s

 

 

 

 

 

 

 

 

 

 

Partner

 

 

 

 

 

 

 

 

 

 

 

 

 

Partner

 

 

 

Gout

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b. Have you or your partner consulted a physician for a fertility or other reproductive

 

 

 

 

Joint pains

 

 

 

 

 

 

 

 

problem?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

Bone infections

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, specify who consulted the physician:

 

 

 

 

 

Bursitis or tendonitis

 

 

 

 

 

 

 

 

Self

Partner

Self and Partner

 

 

 

Backache, back trouble, sciatica

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Foot trouble, flat feet or fallen arches

 

 

 

 

 

 

 

If yes, specify the diagnosis:

 

 

 

 

 

 

"Trick", "locked", or "loose" knee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Back injury or herniated disk

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Painful or trick shoulder

 

 

 

 

c. Have you or your partner ever conceived a child resulting in a miscarriage, still birth

 

 

 

 

Swollen or painful joints

 

 

 

 

or

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other problems with your bones or joints (If yes,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes,

Miscarriage

Still Birth

 

Deformed

 

 

specify):

 

 

 

 

 

 

 

 

Offspring

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If outcome was a deformed offspring, what was the deformity?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever had surgery (including setting of broken bones) on any of your

 

 

 

Was this outcome a result of a pregnancy of yours with:

 

 

 

bones or joints? (If yes, describe):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Present Partner

A Prior Partner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

d. Did the timing of any abnormal pregnancy outcome coincide with your present

 

SKIN: Have you ever had or do you now have any of the following skin

 

 

 

 

employment?

Yes

No

 

 

 

 

 

problems?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List dates of occurrences:

 

 

 

 

 

 

 

 

NO

PAST

CURRENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What is the occupation of your

 

 

 

 

 

 

Hives

 

 

 

 

 

 

 

partner?

 

 

 

 

 

 

 

Eczema

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NERVOUS SYSTEM: Have you ever had or do you now have any of the following

 

Psoriasis

 

 

 

 

illnesses or problems with your nervous system?

 

 

YES

 

YES

Rash on elbows, knees, or scalp

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Frequent headaches

 

 

 

NO

PAST

CURRENT

Rash other than on elbows, knees, or scalp

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Severe stubborn dandruff

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Migraine headaches

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Small itching blisters on the sides of your fingers or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Epilepsy, convulsions, seizures

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

palms

 

 

 

 

 

 

 

Nervous breakdown

 

 

 

 

 

 

 

Excessive sweating on palms, soles, or armpits

 

 

 

 

 

 

 

Depression/Excessive worry

 

 

 

 

 

 

Sores that do not heal

 

 

 

 

 

 

 

Loss of memory (amnesia)

 

 

 

 

 

 

Moles that bleed or get larger

 

 

 

 

 

 

 

Nervousness

 

 

 

 

 

 

 

Change in color of skin (other than suntan)

 

 

 

 

 

 

 

Tremor of the hands or head

 

 

 

 

 

 

New growth on skin

 

 

 

 

 

 

 

Palsey or tremors

 

 

 

 

 

 

 

Other (If yes, describe):

 

 

 

 

 

 

 

Severe head injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Neuritis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Paralysis of any type

 

 

 

 

 

 

ALLERGIES: Have you ever had or do you now have any allergies?

 

 

 

 

 

Other problems (specify):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

PAST

CURRENT

 

 

 

 

 

 

 

 

 

 

 

 

Medications (If yes, please list):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BLOOD: Have you ever had or do you now have any of the following blood diseases or

 

 

 

 

 

 

 

problems?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

YES

 

 

 

YES

YES

 

 

 

 

 

 

 

 

NO

PAST

CURRENT

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

PAST

CURRENT

 

 

 

Anemia

 

 

 

 

 

 

 

Food

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Low hemoglobin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Soaps or detergents

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bleeding disorder

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chromium

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Leukemia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nickel

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sickle cell disease or trait

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rubber

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phlebitis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Epoxy resins

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other problems (specify):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Plants (e.g., poison ivy, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pollen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insect scales

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bee stings

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever had a blood transfusion?

 

 

 

 

 

(NOTE: This section continues at top of next page.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form ARS-182C (11/2000) (page 6)

 

USDA-ARS

 

 

 

This form was electronically produced by USDA/ARS/ITD using INFORMS

 

 

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY NO.

 

 

 

 

OCCUPATIONAL MEDICAL SURVEILLANCE PROGRAM

 

 

 

 

 

 

 

MEDICAL HISTORY (Continued)

 

 

 

 

ALLERGIES (Continued)

 

 

YES

YES

CANCER: Have you ever been diagnosed with cancer?

 

 

 

 

 

 

NO

 

PAST

CURRENT

No

Yes

(If yes, list the year and type of diagnosis.)

 

 

House dust

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type

 

Year

Specific Tissue Diagnosis (If available)

 

 

 

Animal dander, feathers, or fur

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Skin

 

 

 

 

 

 

 

 

Sunlight or cold

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Colon

 

 

 

 

 

 

 

 

Other (If yes, please list):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Breast

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lung

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Prostate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cervical

 

 

 

 

 

 

 

Do you react with:

 

 

 

 

 

Other (If yes, specify type and describe tissue diagnosis and year):

 

 

Rash

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INFECTIOUS/CHILDHOOD DISEASES: Have you had or do you now have:

 

Hives

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

YES

 

Hay fever symptoms

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

PAST

CURRENT

 

Breathing difficulty

 

 

 

 

 

Mononucleosis

 

 

 

 

 

Other (If yes, describe):

 

 

 

 

 

Meningitis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Malaria

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Polio

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rheumatic fever

 

 

 

 

 

 

 

 

 

 

 

 

 

Scarlet fever

 

 

 

 

EARS: Have you ever had or do you now have any of the following problems

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

with your ears or your hearing?

 

YES

YES

Mumps

 

 

 

 

 

 

 

 

 

 

NO

 

PAST

CURRENT

Measles

 

 

 

 

 

 

 

Difficulty in hearing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chicken pox

 

 

 

 

 

 

 

Tinnitus (ringing/buzzing) in right ear

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

German measles

 

 

 

 

 

 

in left ear

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tonsillitis

 

 

 

 

 

 

 

Nasal allergy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gonorrhea

 

 

 

 

 

 

 

Vertigo (dizziness)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Syphilis

 

 

 

 

 

 

 

Perforation of the ear drum

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FAMILY HISTORY: Have any of your blood relatives (parents, grandparents,

 

 

 

 

 

 

 

 

 

brothers, sisters, aunts, uncles or children) had any of the

 

 

 

 

Ear drainage (caused by infection or injury)

 

 

 

 

following YES

YES

 

High fever

 

 

 

 

illnesses or conditions?

 

NO

PAST

CURRENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Anemia

 

 

 

 

 

 

 

Infection of inner ear

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alcoholism

 

 

 

 

 

 

 

Hearing loss by blood relatives (such as

 

 

 

 

 

 

 

 

 

 

 

grandparents, parents, aunts, uncles, brothers, or

 

 

 

 

Allergies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

sisters) before they reached the age of 60

 

 

 

 

Arthritis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other problems with your ears (If yes, describe):

 

 

 

 

 

 

 

 

 

 

 

Asthma

 

 

 

 

 

 

 

 

 

 

 

Bleeding disorders (free bleeder)

 

 

 

 

 

 

 

 

 

 

 

Breast cancer

 

 

 

 

 

 

 

 

 

 

 

Cervical cancer

EYES: Have you ever had or do you now have any of the following problems with

 

Chronic bronchitis

your eyes or your vision?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

YES

Congenital malformations (birth defect)

 

 

 

 

 

 

 

 

NO

PAST

CURRENT

 

 

 

Glaucoma

 

 

 

 

 

 

 

Diabetes (sugar)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Digestive or bowel disease

 

 

 

Cataracts

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Eczema

 

 

 

Conjunctivitis (pink eye)

 

 

 

 

 

 

 

 

 

 

 

 

 

Emphysema

 

 

 

Blurring of eyesight

 

 

 

 

 

 

 

 

 

 

 

 

 

Epilepsy

 

 

 

Vision getting worse

 

 

 

 

 

 

 

 

 

 

 

 

 

Glaucoma

 

 

 

Seeing double

 

 

 

 

 

 

 

 

 

 

 

 

 

Gout

 

 

 

Seeing halos around lights

 

 

 

 

 

 

 

 

 

 

 

 

 

Hay fever

 

 

 

Pain in the eyeball

 

 

 

 

 

 

 

 

 

 

 

 

 

Heart attack

 

 

 

Eyes are often bloodshot

 

 

 

 

 

 

 

 

 

 

 

 

 

Heart disease

 

 

 

Right eye

 

Injured (e.g., scratched, burned, cut,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

High blood pressure

 

 

 

Left eye

 

etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Kidney or bladder disease

 

 

 

Right eye

 

Foreign object accidentally embedded in

 

 

 

 

 

 

 

 

 

 

Kidney stones

 

 

 

Left eye

 

the eye

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Liver or gallbladder disease

 

 

 

 

 

 

 

 

 

 

 

 

 

Other problems with your eyes (If yes, describe):

 

 

 

 

 

 

 

 

 

 

 

 

 

Lung cancer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mental illness

 

 

 

 

 

 

 

 

 

 

 

Mental retardation

 

 

 

 

 

 

 

 

 

 

 

Nervous system disease

 

 

 

Do you wear glasses?

 

 

 

 

 

Psoriasis

 

 

 

Do you wear contact lenses?

 

 

 

 

 

(NOTE: This section continues at top of next page.)

 

Form ARS-182C (11/2000) (page 7)

USDA-ARS

 

This form was electronically produced by USDA/ARS/ITD using INFORMS

 

 

 

 

 

 

 

 

 

 

SOCIAL SECURITY NO.

 

 

 

OCCUPATIONAL MEDICAL SURVEILLANCE PROGRAM

 

 

 

MEDICAL HISTORY (Continued)

FAMILY HISTORY (Continued)

 

 

YES

 

YES

IMMUNIZATIONS, VACCINES, ANTITOXINS: If you have received any of the

 

 

 

NO

PAST

 

CURRENT

following, check the appropriate box(es) and give the approximate dates, if known.

 

Sickle cell disease or trait

 

 

 

 

 

 

 

 

 

 

Date

 

Stroke

 

 

 

 

 

 

 

 

 

 

(mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

Tetanus

 

Thyroid disease

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tuberculosis (T.B.)

 

 

 

 

 

 

 

 

Poliomelitis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ulcer (stomach, duodenal, peptic)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Influenza

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other cancers or leukemia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Typhoid

 

 

 

 

 

 

 

 

 

 

Is your mother still living?

 

No

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Years

 

 

Diptheria

 

If not, please give age at death:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rabies

 

and cause of death:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rubella (German measles)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Measles (Rubeola or red measles)

 

Is your father still living?

 

No

 

 

Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If not, please give age at death:

 

 

Years

 

 

 

 

BCG

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and cause of death:

 

 

 

 

 

 

 

 

Yellow Fever

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Smallpox

 

 

 

 

 

 

 

 

 

 

 

Are you aware of any disease or illnesses that

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

Yes

 

 

RhoGAM (Rh immune globulin)

 

 

 

 

 

 

 

run in your family? (If yes, please list below):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Immune serum globulin for hepatitis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Others (please list):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mantoux, patch test, or other skin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

test for tuberculosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Results:

 

Positive

Negative

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HISTORY OF HOSPITALIZATION: Have you ever been hospitalized?

 

MEDICATIONS: Have you taken any of the following medications in the last

 

 

No

Yes

(If yes, list reason(s) and date(s) of hospitalization.)

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO

PAST

CURRENT

 

 

 

 

 

 

 

 

 

 

 

 

Antacids

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Antibiotics (e.g., penicillin, ampicillin, tetracycline)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Antihistamines

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Aspirin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Benzedrine / Dexedrine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth control pills

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Blood thinners (anti-coagulants)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Codeine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cortisone or other steroids

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diet pills

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Digitalis or other heart pills

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have any problems you would like to discuss with the doctor?

 

 

 

 

 

 

 

 

 

 

 

 

Diuretic or water pills

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

Yes

(If yes, please list them):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hormones

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insulin or oral anti-diabetic drugs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Iron pills

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Laxatives

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Morphine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nitroglycerine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pain killers (aspirin, empirin, anacin, bufferin, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pep pills or Mood elevators

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pills to lower your blood pressure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sleeping pills

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sulfa preparations

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Thyroid medication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tranquilizers, sedatives, or nerve pills

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE AND DATE COMPLETED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vitamins

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Others

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Mo.)

(Day)

(Yr.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form ARS-182C (11/2000) (page 8)

USDA-ARS

 

 

 

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