Document 3Nqvxd2Jv6MXb385OyDYw6B9a

HISTORY QUESTIONNAIRE MEDICAL DEPARTMENT OM-7M B.F. GOODRICH CHEMICAL COMPANY LIVING AGS IP AGE AT RELATIONSHIP YES NO LIVING OBATN FATHER MOTHER o X 7^ X *7 1A Lx BROTHERS / CAUSE OP OEATH f/ FAMILY HISTORY CONDITION OF HEALTH (IF ANSWERED OTHER THAN "GOOD" GIVE 1 ETAILS) -- ** c cl V SISTERS X X X *> if (i t% u Hov you ivtf hod or been treated for PAST MEDICAL HISTORY YES NO YES NO YES NO ALLERGY i/ MUMPS JAUNDICE lX ASTHMA. HAY FEVER SKIN RASH ARTHRITIS ( ^TIS RUPTURE SCIATICA STOMACH ULCERS TROPICAL DISEASES A KIDNEY STONES %/ BACK INJURY \/ UNCONSCIOUSNESS y / y WEUMATIC FEVER FOOT TROUBLE COLD IN THE BACK i/ TUBERCULOSIS TYPHOID FEVER CHEST PAIN y / u i/ Hove you evsr: Boon in auto accidents YES NO i/ TRICK KNEES ANEMIA CANCER DIABETES X FREQUENT COUGH / SHORTNESS OF BREATH IX SPITTING Or BLOOD y' PNEUMONIA . Been treated for nervous or mental disease t/ i/ *1 ux Rocoivod compon totion lor an industrial |X injury y EPILEPSY MENINGITIS MEASLES y HEART TROUBLE y HIGH BLOOD PRESSURE y GALL BLADDER TROUBLE / Had to change jobs for health rtatont V/ Boon refused lift insurance J y MENTION ANY OTHER DISEASES OR INJURIES YOU HAVE NAD 3- />/-/a/0 fc'C & A OPERATIONS AND INJURIES DATE TREATED BY CONDITIONS RE 3UIRINC MEDICAL ATTENTION IN PAST TWO YEARS MILITARY SERVICE BRANCH OP SERVICE LENGTH OF SERVICE RANK ON DISCHARGE ADDRESS w n H- PERCENT DISABILITY BFG65252 OVER- LOCATION_____ 1 HIGH SCHOOL NAME 5 COLLEGE HOBBIES ^/J/S s/J /?- SOCIAL HISTORY l/& C-&T/*n//t LOCATION USE OF ALCOHOLIC BEVERAGES lddzy dtrri-E USE OF TOBACCO (Kind and anounf) /Id (C{Cf/7 S*t >* &) TEAKS COMPLETED /d YftSCOMPLETED DATE GRADUATED DATE GRAOUATCO DEGREES USE OF MEOICINES(Kind and amount) /yd Ad HOW MANY CHILDREN DO YOU HAVE -f^ ===== PRESENT HEALTH STATUS Hov* you had arty of tha following conditions n tho post yaar or do you hava any of thorn now? WEIGHT CHANGE IN THE LAST YEAR BREAKING OUT OR RASH OF SKIN WEAKNESS, CHILLS OR FEVER HEADACHES NERVOUSNESS OR INSOMNIA SWELLING OF HANDS OR FEET PAINFUL JOINTS NOSE BLEEDING, DIFFICULTY BREATHING THROUGH NOSE SORE OR BLEEDING GUMS, ULCER IN THE MOUTH HOARSENESS DIFFICULTY SWALLOWING FOOD OR LIQUIDS CHEST PAIN, ESPECIALLY WITH WALKING COUGH, DRY OR WITH SPUTUM RAPID OR IRREGULAR BEATING OF THE HEART SHORTNESS OF BREATH LOSS OF APPETITE HEARTBURN OR INDIGESTION CONSTIPATION, DIARRHEA OR BLOOD IN THE STOOLS FREQUENT OR PAINFUL URINATION BLEEDING FROM ANY FART OF THE BODY MENSTRUAL PAIN OR ABNORMAL PERIODS Hava you been sick in any significant way since the last examination? Have you hod occasion to see vour physician since lost examination? ENTER DATE OF LAST MENSTRUAL PERIOD HISTORY TAKEN BY YES NO y >y ]/ y !/ / y */ id i/ i/ y y y y y y y y y y y y y c/ (DATE OF HISTORY TO BE INSERTED) fl i 11?* YES NO YES NO YES NO y y y y | l/ u/ / / v/ v/ 1/ ~7 \y ' y y y y / 4 Yr.$ NO ./ & " LXo, wO f - -- ^ ^ (1^ 52 Q) () :oa O jJc cy/jU^ ~ f'fs, '-j u -- y^iL-^ w^~ (".V V yv-v'v -- I efilly that I hov# rviwd lh* information tupplitd by mo and rocorded^on both tidtt of this Madicot History Questionnaire. To the best of my knowledge it is true, correctly recorded ond complete. I authorise any of the physicians, hospitals or clinics mentioned in this questionnaire to Supply complete transcript of my nedicol records to the Medical Department of Olin Mathieson Chemical Corp. SIGNED T' I TN CSS c BFG65253