Document 1yQpELDr8GKL4Qk8L3pbk70o5

22748 - Federal Register / Vol. 51, No. 119 / Friday, June 20,1988 / Rules and Regulations Acc you suffering Iron or have you ever uuftered Iron: 4. Epilepsy (or tits, seizures, convulsions)? b. Kheumatie lover? c. Kidney disease? d. Bladder disease? e. Diabetes? t. Jaundice? 19. CHEST COLDS AND CHEST ILLNESSES 19A If you get a cold, does 'it usually qo to your chest? (Usually Deans more than 1/2 the tine) o iZi o iZi iZ) O O iZ). OO l. Yes __ 2. No `3. Don't get colds 20A. During the pact 3 years.- have you had any chest 1. Yes illnesses that'have kept you'off work, indoors at- home, or in bed? IK YES TO 20A: B. Did you produce phleqm 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) phlegm did you havo.which lacted a week or more? Number of illnesses No such illnesses Did you have any lung trouble before the aqe of 1. Yes __ Id? Have you ever had any of- the following? 1A. Attacks of bronchitis? l. Yes __ IK YES. TO 1A: B. was it confirmed by a doctor? l. 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 __ IP 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 Hi ja. Hay Fever? W YES TO 3A: B. Was it confirmed by a doctor? C. At what age did it start? 23A. Have you ever had chronic bronchitis? IP YES TO 23A: B. Do you still have it? C. Was it confirmed by a doctor? D. At what age did it Start? 24A. Have you ever bad emphysema? IP YES TO 24A: B. De you stillhev? it? C. Was it confirmed by a doctor? D. At what age did it etart? 2SA. Have you ever had asthma? IP YES TO 2SA: B. Do you still have it? c. Was it confirmed by e doctor? D. At what age did it start? E. If you no lonqer have it, at what age did it stop? 26. Have you ever had A. Any other chest illness? if yan. please soecifv ,, l. Yes __ 2. No __ 1. Yes __ 2. No __ 3. Does Not Apply _ Age In Years __ Does Not Apply __ 1. Yes __ 2. NO __ 1. Yes __ 2. No __ 3. Does Not Apply __ 1. Yes __ 2. No _ 3. Does Not Apply _ Age in Years _ Doss Not Apply __ 1. Yes __ 2.-No __ 1. Yes __ 2. No _ 3. Does Not Apply __ 1. Yss __ 2. No __ 3. Does Not Apply Age in Years __ Does Not Apply ;__ l. Yes _ 2. No 1. Yes __ 2. No __ 3. Doe NQt Apply ^ 1.. Yes __ 2. No 3. Does Not Apply __ .Age in Years Does Not Apply _ Age stepped __ Does Not Apply __ 1. Yes _ 2. No __ y GLEASON-000996