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LEWIS 1_ IMMERMAN. M.D. CHARLES A. PRIVITERI. M.D.
PASSAIC RADIOLOGY ASSOCIATES. P.A.
643 MAIN AVENUE PASSAIC, N, J. 07089
November 15, 1976
EZRA SCHLOSSBERG. M.D. SAM I. BROWN, M.D.
Re: Hemice, Joseph Both hands, PA
Hans Tauber, HD Hedical Director The Pantasote Company 893 Park Avenue New York, New York 10021
Dear Dr. Tauber:
Radiographic examination of both hands showed no bony abnormality.
Conclusion: No bony abnormality
Thank you for the opportunity to examine this patient.
Yours truly
n
LU :ehs
Lewi-s- L. Immerman, MD
UCCLEW0379
T^E PANTASOTE
COMPANY OP NEW YORK, INC.
26 JEFFERSON STREET, PASSAIC, HEW JERSEY 07055 AREA COOE 201-777-8500 TELETYPE 710.983.7108
Y . VA f?t
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You recently participated in the Pantasote Medical Surveillance program for possible side effects of vinyl chloride exposure.
Extensive blood tests, x-rays, and a physical examina tion were conducted to provide the physician with the necessary information.
The teste conducted and x-rays taken by the Company have shown no abnormalities.
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The results of the tests and the x-rays will be forwarded to your designated physician upon the completion of a "Request for Information" form, which you may obtain in the Personnel Office.
M.D
UCCLEW0380
THE P ANTASOTE fp]
COMPANY OF NEW YORK, INC. I IHV
pmpi nvFF*s mamf
PLANT NAME AND LOCATION____________________________
Memice. Joseph________________ abf6-27- 18pmpi nVMcpr datf 9-26-60
ADDRESS
------------------------------------------------------------------------------------------------------ DATE___ 4-25-77 DEPT.
PAST MEDICAL HISTORY:
YES
D
NO Head or back injuries Convulsions (flu, epilepsy) Diabetes Ulcer O Heart Disease Tuberculosis
Hepatitis (Date Use of Drugs
)
YES
Hava you ever been hospitalized?
YES NO
If yes, when, where and for what reason_________________
NO
Rheumatic fever Asthma Kidney Disease Liver Disease
Bursitis -- Arthritis
Permanent defects or deformities
Allergic Reactions
Have you ever had surgery?
YES NO 0
If yes, when was the surgery performed and what was the surgery for.
Have you ever received any blood transfusions? If yes, give dates and details
YES NO
Are you presently taking any medication?
YES NO D
If yes, specify for what reason________________ :________________________________________
Do you smoke?
YES
NOD
If yes, number of packs per day________
Do you drink alcoholic beverages?
YES
Beer: How many cans or bottles dally
Liquor (Include wine): How many drinks daily
NO D
Have you ever been declined insurance for medical reasons?
YES NO
Have you ever been declined by a blood bank when donating blood?
YES NO
INDUSTRIAL HISTORY:
Have you ever, due to your work, received or have:
Amputation Fracture Back Injury Burns Allergic Reaction
Lung Disease Hernia Other -- Explain
Have you ever worked In an area of excessive noise levels?
YES D
If yes, were ear protectors worn?
YES NO
NO
Have you ever, due to your work, been exposed to:
YES
NO
Mining, sandblasting, stonecutting or foundry works. If yes, the number of years
in the industry:years
D Asbestos, grinding, polishing metals or pottery. If yes, the number of years in the industry:years
What companies have you worked for before being employed by Pantasote? {Give approximate dates, job titles, or positions held and name of company).
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N
What chemicals or drugs were you exposed to with your previous employer(s). (Give names of chemicals or drugs and dates exposed)
FAMILY HISTORY:
Are your parents alive? Father
YES
NO
Mother
YES NO O
If not, give the cause of death and age at the time of death_______________________________________________
Do you have brothers or sisters?
YES
NO
If yes, are any deceased?
YES
NO
If deceased, give his/her name(s), age, and cause of death _
The questions as I have answered are to the best of my knowledge and I understand that intentional falsification of any of the above data will mean immediate dismissal.
Signature Date___________________________________________________________________________ _______________
l hereby authorize the doctor or his designated representative to give me a physical examination and to draw a blood specimen for laboratory tests as indicated.
Signature___________________________
'" Date -
FOR DOCTOR'S USE ONLY:
*FuA rUP
UPPER:. LOWER: NERVOUS SYSTEM:
UCCLEW0382
TEST NAME
CHEM-SCREEN PROFILE CALC 1UM
PHOSPHORUS BUN CREATININE
BUN/CREAT RATIO URIC ACID
GLUCOSE (CS) TOTAL PROTEIN ALBUMIN GLOBULIN ALB/GLOE RATIO TOTAL BIL1RUEIN DIRECT ElLIRUBIN TRANSAMINASE,SGO TRANSAMINASE,SGP ALK. PHOSPHATASE
LDH CHOLESTEROL
IRON TOTAL LIPIDS SODIUM POTASSIUM CHLORIDE 6"GLUTAMYL TRANSPEP. TRIGLYCERIDES CBC WBC
RBC HGB
HCT MC V MCH MCHC
DIFFERENTIA L**POLY i!YMP H
MONO EOS
BASO SEROLOGY (ART) SEDIMENTATION RATE
,,
RESULT
UNITS REFERENCE RANGE
9.10
M6/DL
2.30
MG/DL
17.00
MG/DL
1.00
MG/DL
17.00
4.80
MG/DL
103.00
MG/DL
7.10
GM/DL
4.20
6M/DL
2. 80
GM/DL
1.54
0.56
MG/DL
0.14
MG/DL
32.00
I.U./L
29.00
I.U./L
28.00
I.U./L
249.00
I.U./L
232.00
MG/DL
99.00
MC6/DL
0.62
6M/DL
137.00
MMOL/L
4.30
MMOL/L
104.00
MHOL/L
11.00
UNITS/L
97.00
MG/DL
9.50
THOUSAND
4.97
MILLION
15.20
GM/DL
46.60
PCT
94.00
U3
30.80
UUG
32.90
pa.
62 PCT.
27 PCT.
7 PCT.
2 PCT.
1 PCT.
NON-ftEACTIVE
11.00
MM/ HR
8.8-1C.8 2.0- 4.7 6.0-25.0 0.5- 1.7
2.5- 8.5 65- 13 C
6.2- 8.3 3.6- 5.2 1.9- 3.7 1 0" ^ C.1- 1.7 0.0- C.3 1.6-70.0 1.0-7C.0 1C.C-5C.0
90- 250 125- 300
45- 200 0.3- 1.0 13 4- 145 3.5- 5.5
96- 110 1.0-40.0
5C- 20C 4.8-10.8 4.0- 6.C 11-C-17.0 35.0--52.0 82.0-99.0 26.G--32.C 31.0-36.0 34.0-77.0 16.0-53.0 C.0-12.C D.C;- 8.0 G. C-- 2.C
2.0-2C.0
- T CENTftAL UBORATORY FACIUTT^-T^i
Commtrca Way Hackansaek,' NawMaraay 0760#?
mrniM.Hmi^ I.mfc
UW M, **
JOSEPH E. O'BRIEN, M.D. PAUL A. BROWN M n
UCCLEW0383
LEWIS L. IMMERMAN. M.D. CHARLES A. priviteri, m.d.
PASSAIC RADIOLOGY ASSOCIATES, P.A.
<69 MAIN AVENUE PASSAIC. N. J. 07098 Telephone 773-85B2
Harch28, 1977
EZRA 8CHLOSSBER6. M.D. SAM 1. BROWN. M.D.
Re; Memice, Joseph PA Chest / PA Hands
Hans Tauber, MD Medical Director The Pantasote Company 893 Park Avenue New York, New York )0021
Dear Dr. Tauber:
Radiographic examination of the chest shows no significant abnormality of the heart or lungs at this time.
Radiographic examination of both hands showed no bony abnormality.
Thank you for the opportunity to examine this patient.
SIBrehs
UCCLEW0384