Document wgOBdvBn5Lw3XQvQ97Ljw7Xz3

lljKrWn ^^Date of Birth 1 Race Occupational Record Past Medical Record Rheumatic Fever Chorea Scarlet Fever Other Conditions Personal Record Diet Appetite Family Record Father Mother Physical Examination Appearance Build Skin Lymph Nodes Mouth and Throat Teeth Ears Nose Eyes Urine S.G. Sugar Blood Hemoglobin Remarks THE ASSOCIATED ETHYL COMPANY LIMITED INITIAL BLENDER EXAMINATION FORM Marital State Children Weight (lb.) Height (ft. in.) Temperature Pulse Rate and Rhythm Diphtheria Pneumonia Pleurisy Bowels Micturition Brothers Sisters C.V.S. B.P. R.S. A.S. G.U.S. C.N.S. Cranial Nerves : Reflexes : Motor System : Sensory System : 1 Grip: Albumen Microscopy Notes overleaf If 001022 6 N29803 TO THE CHIEF MEDICAL OFFICER THE ASSOCIATED ETHYL COMPANY LIMITED fmm form M 17^ THE ASSOCIATED ETHYL COMPANY LIMITED MEDICAL SERVICES OVERSEAS GENERAL REPORT BLENDING OPERATORS PLANT {Name and Location). STATE OF HYGIENE {Plant and Equipment). EMPLOYEE {Name). MEDICAL {Initial or Routine). REPORT {Fit or Unfit). DATE REMARKS A '! W ' :,v .; -- r ': :.. . 1 ` ' - / / > ', _ ' - : 'V" V . - S-ilr* - nm^ 4,?8V. V A':p\" -'i' V v:rivr - V :.r ``r ^. - Vi f i-.' t " .t- ' * -- .; Kf 0010228. ->* ' " . ' _........ THE ASSOCIATED ETHYL COMPANY LIMITED ROUTINE BLENDER EXAMINATION FORM .Vs ---------------------- 1------------ Wpste LOCATION i Pallor Weakness i :i Fatigue Sleep Disturbance Insomnia Anorexia indigestion j ! j j 1 j i; Hi j i !i 1 i Constipation i | Weight { Anxious Expression ; I ii .... ... L ______ Metallic Taste , EMPLOYER r i ii it i ii ii i ...... ...... i i 1 Headache Sensory Disturbance j i i Dysuria Temperature Pulse | 1 Blood Pressure Tremor Grip (Rt.) Grip (Lt.) Teeth Gums j i >( j j j j j ---- Urine Ph. Urine Albumin ! Urine mg./L. (Pb.) ; Urine Sugar Haemoglobin Canisters last changed No. of blends since last examination \ ' 1 i 1 i i i i Masks ||!!! -------------------- ;------------------------------------i_______ 1_______ _____ Gloves !i; Clothes ; _____ L ! '! i' | - !i 1i _______ 1_______ i i ij ! s 1 i NOTE, (i) Where the reply is_ " Yes " or " No " indicate by + or - , where " satisfactory " by /, where unsatisfactory by X. (2) This form is to be used for completing form M 18b and retained. g- 00102^9 -- fO THE CHIEF MEDICAL OFFICER i ASSOCIATED ETHYL COMPANY LIMITED HYL BLENDERS AND EQUIPMENT REPORT LOCATION s* ...-..-.T===== = ^NDS SINCE LAST EXAMINATION : j Report Equipment Report 5VMPTOMS : Cardiac............... Respiratory........ Alimentary......... Genito - Urinary. Central Nervous. SPECIAL QUESTIONS : Sleep...... Appetite Weight... Bowels... SIGNS : Heart : BP.T C.N.S. : Mouth : Urine : Size :................. Systolic.............. Reflexes............ (Teeth)............. Albumin........... Rate and Rythm. Diastolic........... . Tremors.......... (Gums)............ Sugar.................. Cannisters Last Changed: Masks : * In Good Condition/Require Renewing Gloves : * In Good Condition/Require Renewing Clothes : * In Good Condition/Require Renewing Other Equipment: * Delete as Necessary Special Examinations (When Intoxication is Suspected). Remarks Haemoglobin____________ ________ Lead in Blood________ ...... ........mg./100 Gm. Lead in Urine............................................................ mg./Litre REPORT : This Man is Fit and Well, or :. Date........................................... g 001023 0 Doctor... NOTE.--This Form is to be Sent to the Above Address After Completion From Form M 18a.