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EMPLOYMENT HEALTH QUESTIONNAIRE
NAME: COMPANY
r}lj9f)U\_0jLA()i A .AGE: fit \jyy\JL
_DAT E: Cf - /Q '</ HEIGHT: {tfj " WEIGHT: /
HISTORY OK PREVIOUS LUNG DISEASES AND YEAR:
.
PNEUMONIA: /\J^>
AZ&________________ ASTHMA:
Cl 1RONIC BRONCHITIS: 'NT)
EMPHYSEMA: -AJr >
ALLERGIES: N >TUBERCULOSIS:
A//)
PNEUMOCONIOSES (Silicosis, Asbestosia, Coal-Miners Disease. Etc.):
~ ~Ajf)
II1S TORY OF HEART DISEASE:
SMOKING HISTORY:
'
DO YOU SMOKE CIGARETTES NOW?
y YES X
NO
IF YES, HOW MANY PER DAY? /^MVHEN DID YOU START (AGE)?
IK NO, DID YOU EVER SMOKE CIGARETTES? YES NO
IK YES, WHEN DID YOU START (AGE)?___WHEN DID YOU STOP (AGE)?______
HOW MANY PER DAY?
IX) YOU SMOKE CIGARS?
YES___________
NO
DO YOU SMOKE A PIPE?
YES___________
NO j/^
DO YOU HAVE ANY OF THE FOLLOWING SYMPT<OMS: IF YES, EXPLAIN.
SHORTNESS OF BREATH (DSYPNEA): mi>
AFTER EXERTION: Aft)
COUGH: HD
DRY: AJ o
EXPECTORATION:
AJaBLOOD SPITING:
%PAIN OR DISCOMFORT IN REST:
LOSS OF APPETITE
a____ ;
~7$T> LOSS OF WEIGHT: 2^o
7Cfc~
HAVE YOU EVER WORKED:
AS A HARD ROCK MINER?
YES
WITH ASBESTOS?
YES
WITH DIATOMACEOUS EARTH? YES
AS A COAL MINER?
YES
IN A JOB THAT REQUIRED AN
X-11AY FILM BADGE?
YES
AS A WE USER?
YES
IN A TEXTILE MILL?
YES
WITH TALC?
YES
IN ANY OTHER DUSTY JOB?
YES
WITH EXPOSURE TO EXCESSIVE
YES
NO ^TROM NO ^ FROM NO FROM NO ^HIOM
NO ^ FROM NO ^FROM NO FROM NO FROM NO r FROM
NO *""FROM
TO TO TO TO
TO TO TO TO TO
TO
CONFIDENTIAL
in f o r ma t io n r edac t ed
CYWI 3-001X70
N14515
DIRECTOR*
ROBERT C. BOYD. M.O. RICHARD THOR*. M.D.
SENIOR CONSULTANT PHILIP FALK. M.O.
CLEARING INDUSTRIAL CLINIC
^ Sixtv-Fifth Street / Chicago, Illinois 60638 / 767-6600-01 -02-03
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CONFIDENTIAL
in f o r ma t io n
REDACTED
cvm 3-001171 N14515.01
American Cyanamid
1/5/84 2/10/84 3/8/84 4/13/84 5/17/84 6/13/84 6/21/84 7/20/84 8/15/84 9/6/84 1/5/84 2/10/84 3/8/84 * 4/18/84 5/17/84 6/13/84 6/21/84 7/20/84 8/15/84 9/6/84
722mcg per DL 795mcg per DL 744racg per DL 7 48mcg per DL 688mcg per DL 833mcg per DL 701mcg per DL 630mcg per DL 672mcg per DL 726mcg per DL None
102mcg per DL 662mcg per DL 862mcg per DL 785mcg per DL None 817mcg per DL 814mcg per DL None None
Spirometery was performed and Che requirements of the OSHA lead standard were performed. These reports are attached.
PRESENT CGKPIAINTS: At the time of this examination this subject indicates that he feels fine and has no complaints. He denies any symptomatology and indicates Chat he has no feeling of tiredness.
GASTROINTESTIONAL SYSTEM: He denies any gastrolntestlonal complaints.
RENAL: He denies any urinary complaints.
CARDIOVASCULAR: He denies shortness of breath, ankle edema or any discomfort in his chest.
NEUROLOGICAL: He denies any neurological symptoms.
Examination of the patient reveals no abnormal findings in the gums. There is no abdominal tenderness or any abnormal abdominal findings. On Neurological examination the achilles and patellar reflexes were normal. The Romberg test was normal. There was no evidence of a wrist drop. There was no impairment of sensations. The cardiovascular examination revealed the blood pressure to be 120/78 and the pulse race was 70. The heart sounds were normal.
CONFIDENTIAL
in f o r ma t io n r edac t ed
CYWI 3-001172
American Cyanamid
RE:
A review of the laboratory testing reveals some elevation of the creatinine serum level. The BUN serum level, was within normal limits. The soirometery is within normal limits. Tne complete urinalysis and complete blood count were within normal limits. From this examination and other tests, it is my opinion this employee may continue at work, without increased, risk or impairment of his health from further exposure to lead.
Very Truly Yours
REBtrls
CONFIDENTIAL
in f o r ma t io n r edac t ed
CYWI 3-001173