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ORDER FOR MEDICAL TREATMENT
// (MCPk
TO: Dr.
^Prist__________ _
Kindly zander treatment neceuory to Injured nomed below subject Jo provtstem of Work* men's Compensation Acti
REPORT OF DIAGNOSIS
Deor Doctor; Pleove complete, fold, seal ond moil Shi* report immediately after first treatment.
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NGC 06901
fiEON Company
CONFIDENTIAL HEALTH HISTORY
HEALTH FOi--
^T NAME . - V- ' -
first
Ml EXAM DATE //
SOCIAL SEC. '
Sf'A
/ FAMILY HISTORY (check and list relation)
BHEART ATTACK- JH
m HIGH BLOOD PRESSURE DIABETES
My SB/.F
'
ALCOHOL USE (CHECK)
/
DAILY 3 DAYS/WK ___ RARE \/NONE
TOBACCO USE
CURRENT USER FORMER USER NEVER USED YEAR STARTED: 19 _fj_ 1, YEAR STOPPED: 19
0 CIGARETTFS
PACKS/DAY
CIGARS PIPE CHEW
ASTHMA/ALIJRGIES
LUNGDISE^SE^ ^
E CANCER-
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MEDICATIONS AND ALLERGIES
Ceie&&+. *J PERSONAL PHYSICIAN(S)
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SHADE BOX IF YOU HAVE THE FOLLOWING PROBLEMS
PAST PROBLEM
PHYSICIAN HISTORY REVIEW
THE EXAMINING PHYSICIAN MUST COMPLETE THIS SECTION
SEVERE HEADACHE VISUAL PROBLEMS IMPAIRED SENSE OF SMELL
HEARING PROBLEMS m SINUS CONGESTION m IRRITATION OF EYES/NOSF.
HOARSENESS MORNING COUGH PERSISTENT COUGH PHLEGM FROM CHEST TROUBLE BREATHING
D ASTHMA m HIGH BLOOD PRESSURE HEART DISEASE CHEST PAIN ON EXERTION
DIABETES ELEVATED CHOITiSTEROL DIGESTIVE PROBLEMS HEPATITIS/IiVER PROBLEM KIDNEY/BLADDER PROBLEMS ANEMIA/BLOOD TRANSFUSION SEVERE INFECTIONS CANCER NUMBER OF CHILDREN: Ji___ O ANY REPRODUCTIVE PROBLEMS
FAINTING OR DIZZINESS SETZURES OR EPILEPSY WEAKNESS OR NUMBNESS LOSS OF STRENGTH BACK PAIN
B PAIN IN JOINTS
SKIN RASH OR IRRITA TION PSYCHOLOGICAL PROBLEMS DRUG OR ALCOHOL DEPENDENCE
PLEASE REVIEW ALL POSITIVE RESPONSES- VERIFY SMOKING AND ALCOHOL KISTO
I JST ANY OTHER PROBLEMS OR ISSUES WHICH YOU WOULD LIKE TO DISCUSS WITH THE PHYSICIAN
NGC 06902
L V CHEM ICAL Ml
MALE
PLANT NAME.*.., AREA TASK JOB SHIFT DATE-. E/T w .PPM PJHP POS
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S96846D - B.F.G. PERSONNEL HON ITDR - PERSONAL DATA
01/01/8A TD 12/31/84
DATE 02/15/85 imt 104347 P AS E
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NOC 06905
R?b*46 - >**% MAS*iHi A0AITO* - F0tSGftt DATA
01/01/85 TO 12/31/*5
BATE 02/03/86 TIA 091359
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'(-PL ATfT-- NAME
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014 8 2 360 e 032685 420
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014 0 00 360 6 07 1 685 450
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014 QCG 360 8 090485 435
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014 806 360 8 110485 425
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MQC 06906
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PLANT KANE PLAQUEMINE
AREA TASK JOB SHIFT DATE.. E/T . - YPPH
014 802 360 C 011284 390
1.17
PLAGUEMINE
014 802 360 C 020 884 015
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PL f TEW1NE - - -014 -- -802 -36 0 - C 021784 - 420 --- 2^rr
PLAQUEMINE
014 0 00 3 60 C 031684 390
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PLAQUEH1NE
014 802 360 c 040 984 015
3.97
PLAQUEMINE-------- 014 - 802 360 -- c - 050284 420-- S7ZT
PLAQUEMINE
014 802 360 c 062684 420 34.06
PLAQUEHINE PLAQUEMINE
014 802 360 c
014 ' BTJ2 36 0 - c
070384 420
1.92
080 384 435 - 12 9.51
PLAQUEMINE
014 802 360 B 091084 420
3.24
PL AQUEHINE
014 602 360 B 110584 420
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BRK TH RESP NO 7
7
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PLANT NAME..!.. AR E A TASK JOB SHIFT DATE. . E/T VALUE > I15DB
PLAQUEMINE
014 0 00 360 C 031284 600 177.20
R968460 - B .1=. G rT ETfSUNNEL MONITOR - P ERSDTtAL DATA........ ............... .
01/01/84 TO 12/31/84
DATE 02/15/85 TIME 104347 PAGE
1
NOC 06907
FD CHEHICAL HI
MALE
PLAKT MAKE * AREA TASK JOB SHIFT DATE. .
PL AfilUEMINE
051 0 00 101 E 012 384
PLAOUEKINE
051 000 101 E " 020 284
E/T 420 435
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R9&84GD - B-F-G- PERSONNEL HQNITQR - PERSONAL DATA
t)i/0tm^r0-I2/31/8^
DATE T)2/i5/-85' TTMF 10 4 347 P A& F
1
NGC 06908