Document MJ2Nro6kJeK0D5w7rvm7bvgNj

Federal Register / Y o l.\5 ii No. 119 / Friday, June. 20,1988 / Rules and Regulations D. Are you suffering from or bave:.-you ever suffered tiro*: a. Epilepsy (or.'fits. seizures, convulsions)? I*~1 iZj b. Bheumatic fever?' cZi . . <3 c. Kidney disease? ; (Hi (3 d. Bladder disease? e. Diabetes? t. Jaundice? 19. CHEST COLDS AND CHEST 101,HESSES tZr o. - 13 ' ' iZi (Hi 1Z1 19A. It you get a eold: does it `usually oo. to yoor t. :v* 2. chest?. (Usually-means sore than 1/2 the;tiae) * 3. Don'.t get .coi'ds _ 20A. During the past 3 years, nave yog had:any chest i. -Tee- 2. No illnesses'that have kept you oft work-^ indoors at home. or.in bed? .It TES -TO' 20A: . B. Did yoo produce-, phlegm with any of these chest . 1`. 'Yea . 2.N0 illnesses? Does Not: Apply __ C. In the last 3 years, bow maoy such illnesses- . Number.-,of -illnesses __ with.-(increased)-phlegm did.you have which .-.No such'.illnesseo __ . lasted a week ocmore7 21. Did you bave any lung trouble before the age of - lv-Yes _ 16? 2,*Ho 22. Have you ever bad any of the following?; 1A. Attacks of bronchitic? r. Yes Z ` 2. Ho __ IK TBS TO 1A: B. Mac it confirmed by a doctor? ' ' IV Yes 2.=No __ 3v Does Not.Apply __ c. At what age was your f irst'attack? ' . \Age::in-;Years.-' '__ -Does Wot. Apply;.. - 2A. Pneumonia (include bronchopneumonia)? . * .`2/Ho' ' IK YES-TO 2A: -- B. Mas it contiraed by a-doctor?. ; ' ' / l. Yes 2v.'No __ '3:-Doies'Hot App'iy- __ C. At what age did you first have it? '-: .Age-in': Years: ___ Does-NUi-j'A'pply 3A. Hay Fever? tK.YKS TO 3Ar B. Mas it confirmed by a doctor? .. C. At what age did it start? . 23A.'Have you ever bad chronic bronchitis? IK YES TO 23A: B. .Do yoo ctill have it? C. Was it confirmed by a doctor? D- At what age did it start?- 24A. Have you ever bad emphysema? IK YES TO 24A; B. Do you ctill have it? C. was it confirmed by-a doctor? D. At what age did it start?- 2SA. Have you ever had asthma? IK YES TO 25A: B. Do you still have it? C. Was it confirmed by a doctor? ,D. At what-age.'.did it start?. E. It you no longer have it, at what age did it 6top? 26. Have you ever bad: A. Any other chest illness? If yec, please specify ___________ 1. Yec- 2. wo 1.. Yee _1 : 2. Ho __ 3.. DoeeTlof Apply . vAge. in .Years ___ Does Hot Apply _ 1. Yes__ 2. Ho____ 1. Yes _ .. 2. wo _ '3.. Does Not Apply '__ l. Ys __i 2.. Ho 3..Does Not Apply. __ Age in Years __ Does Not Apply __ l. Yes. _ "2. Ho 1.. Yec __ . .2. Ho\__ 3. Does Not Apply ___ 1. Y.e6 _ 2. Ho 3. Does Hot Apply 1 Age in .Years -- Does Hoi Apply 1. Yes __ 2. No .__ l. Yes 2. No 3. Does Hot Apply. `__ * 1. Yes _ - 2. Ho _ 3. Does Not Apply _.__ Age in Years ' ' _ Does Hot Apply Age stopped Does Not Apply __ 1. Yec _ 2. No __ .22771 GLEASON-001019