Document 1gZ9a4y2YEgrMx5a4NRrx9qDa

Federal Register / Vol. 51, No. 119 / Friday. June 20,1986 / Rules and Regulations , 13. RECENT MEDICAL HISTORY 13A. Do you consider yourself to be in good health? ' ' . Yes ____ No If NO. 'state. reason .` . 13B- In the past year.' have .you developed: ' ' Epilepsy?. RAeunatlc fever?. Kidney disease? Bladder, disease? . Diabetes? . *. Jaundice?. - cancer?. M. CKES.T COI.PS AND CHEST ILLNESSES - Yes No .` ' ~ ._ . - . ' __ ' _ __ HA. It you'get a cold, does it usually oo to your .chest? (Usually means more' than 1/2 the,time) l. ires 2. no _ , 3. Don't get colds _ ISA. During tne past year, have you had. any chest illnesses.that have Kept you off work, indoors at home, or in.bed?' . l. Tec. 2. No 3. Does Not Apply IE YES TO ISA: 1SB. Did you produce phlegm with any of' these chest il.lnecsee? isc. in the past year, now many such illneuues with (increased) phlegm did you have Which lasted a week' or more? 1.. yes ___ 2. No __ 3. Does Not Apply Number of illnesses No such illnesses ~~ 16. RESPIRATORY SYSTEM'' in. the past year-have.you had: Asthma ''iS-StJfa ! - "rutmet Consent , on Positive Answers- -- Bronchitiu Hay Kevet Other A1lergies BltUMO CODE 4510-W-C Pneumonia Tuberculosis Choct Surgery Other Lung ProblemsHeart Disease Yec or No ______ _____ _____ . Further Coaamit on Positive Answers Do you have: Kieguem. colds Yes or No _____ Answers Chronic cough _____ Shortness of breath when walking or. climbinq one Might or stairs . ______ Do you: Wheeze ______ Cougn up phlegm ' Smoke cigarettes ' Packs per day. How many years Date Signature 22775 GLEASON-OOI023