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J <. jai. AMw' jV, M.D* ' JIUT A. CAPUT!. M.D
HA2O10 L GtAPP, MJ>. ' JOHN N. STtACKAN. Mj>.
NAME:_____________ _____________ Proseat defies (Wkat 4* yo J)
BWtiAiW
iitxu iiaiWiWMk
755 TONAWANOA STRUT SUPPAIO, N. r. 14207 TDmONii 075.1514
PBUOOIC HEALTH EXAMINATION RB>ORT
date, 1/14/77
emkoy. Georgia Pacific
Ewy day
Hc*./doy
dayt/wk.
eeaths/yr.
Prerieei eepaserei where -- when -- and tar hew tang Silica --rand foundry, aieing. gaorrylng. coroaics Silicates -- talc, asbestos (typo) aiding. Billing, fobricottan, application, textiles, other
tart
yiort.
INQUIRY
1. Cough 2. Chcit pain 3. SOS al ml 4. 505 an effort 5. Expectoration 4. Siaap Oat ha. 7. Pillows 0 -1 2 3 1. lass wgr./appclltc 9. Increasing fatigue 10. Dysphagia 11. Change in bowel habit 12. Blood loss
Coafh Vomit Bloody steal Slack steel Urine Skin 13. ieg eigor/pipe/eights .
J) #pki./<^fof
YCS NO A* /' >
S'
S' > t/
PHYSICAL EXAMINATION___________AGE;________________HEIGHT; MUCOUS MEMBRANES (pigment, pallor, neoplasia)
WEIGHT:
CHEST:
CONTOUR EXPANSION MOBILITY DIAPHRAGMS AUSCULTATION
HEART: Rhythm, rata, tones, murmurs, B.P.
ABDOMEN: liver/5pleen
EXTREMITIES: Edema, dubbing, atrophias - ' 1 '
N' 'ROLOGICAl
PCN
OTR
CUTANEOUS
Dermatitis Pigmentation Neoplasia
Examinee's Signature
Signature
ADENOPATHIES
VENTUATltfKt F.V.C. =
W(n)
Fff 25%-75%
I'tf
IMPRESSION.
NORMAL
F. E V.3 = Utera/minute
RESTRICTIVE
ELECTROCARDIOGRAM
Anoxias
Q
P Pulmonale*
Right Heart Strain:
Abnormalities of rhythm:
Abnormalities of conduction:
Other:
NO DIAGNOSTIC ABNORMALITIES ST-T segment changes
BLOOD COUNT
NORMAL
ABNORMALITIES
BLOOD CHEMISTRIES
SMA 12/60: See Attached SERUM ENZYMES:________________________ SERUM ELECTROLYTES: Na+ K+ Mg++ SERUM ALPHA I, ANTI TRYPSIN SERUM ELECTROPHORESIS: See Attached
BLOOD LEAD:___ ___________ _ MICROGRAMS %
V 'ELLANEOUS: ACHLORHYDRIA (DIAGNEX): OCCULT BLOOD:
URINALYSIS:
ALBUMIN___ SUGAI
URINE LEAD.
mf NORMAL CHEST XRAY
ABNORMAL
-MICROGRAMS/UTBR URINE SULPHATE RATIO UICC/dNClNNATl
%
Moderate prominence of the right root. Some increased radiability in
both uppers and in the left base. At the left base at this time are
noted some pleural changes lying immediately above the diaphragm; these
are not evident in the preceding film, #8894, taken 10/21//5. Lateral
projection also suggests some alteration in the left leaf of the dia-
OTHER
phragm, some tendency to blunt the costophrenic sulcus. Changes are not evident in the earlier film. Attention is directed to the history which
indicates some pulmonary complaint and some change in the bowel habit. It
should also be noted that ventilation studies have been decreased slightly
over the previous study.
ENVIRONMENTAL DATA: sample typo
duration
Examinee does have an abnormal chest and abnormal ventilation studies; he asbestos: Number Fiber* > 5 Mu./Cucm. should be so informed. Please advise. Audiometric
siuca Mg*/m*
study, incidentally, is entirely satfactory.
M1SC. & SUMMARY:
QlflvALO INDUSTRIAL InZDJCAl CE3
7M TONAWANDA RIBT
SUPPALO, N. Y. 14207
Taiagfcaaa 075-1414
EXAMINEE:.
pu>invm
PREPLACEMENT
KSA5SNG EVALUATION SU&LSU3NT
PERIODIC
BASELINE Yet] No]
19' 10.ZB2 ^.1________ __________________S.S. No.,
. AGE-li.
PREVIOUS
DATE,
Georgia Pacific
JOB ASSIGNMENT,.
FOR WHOM,
IS PERSONAL PROTECTIVE EQUIPMENT WORN |Ys No
hrlinMl OccapaKaaal Hiitoryi.
SSAtVJNATION
hftiiwul Medical Miltory,.
Allargiatlajvry-
Ringing in Eon-
-M>W Con.
-VarHgou. -tanning I
Ears Drums Canal
Noso
R
L
APPLICANT'S (VALUATION OP HCARING STATUS
Nonnol
O
Not Normal
'tei Irnwbla hearing
Oantfonl 0
Varakin O Yl
Onto,
Q
Pragtonian 0
la Gravpt 0
an Avdiloria 0
In Natty Ptacm
At Dittonco
Cioto
Telephone
todio-TV Q
Woman aad Childntn Q
ItutM of tinging ia Can 0
Three* Tuning Torlt
AUDEOW2TO2.A B* &fifJX&?bw39
0..._____1/14/77
. Tirno:
FIEOUB4CY - HERTZ (Ha)
It Kar:!
Q 10
<A " <9
125
250
500
1000
2000
!1
i f'
yi *i / vr
i-
/*
go
ia
.Intarvol tinea last noisa axposura.
/
V iNJ \ > r /\ r /
"7 7
A ift O CVSItU OSHA PROPOSED SYSTEM ___
tight Car Hb
loft Ear
x..
\Q
250 500 1000 2000
L/j..J <T ]
v" ;i
__J000___
c 'r 4000
*r> ->
ci
S3 <1* Crpte Mateat / sl Ai'rfVrtv'
U2W//////////A
a
ma W. tot
U o 4000
tin
(000
T - AVHAGf
_3Jl T4. ia
/
/
AUDIOMETER AM. NAT'l STAND SPEC (ANSI-1969)
LEPT EAR RIGHT EAR
AIR
CLUE ij v/\
oRED
(ONE
<S)
V-/
Examine#'s Signature,. Exominer:____________
J
OtaT*A: CAfUTl, M.O .
MA201D L 6WT, MJ).
JOHN N. STIACHAN, MJ.
I lit^
I turih
W<iillu a
7SS TONAWANOA STUn
UffFAtO, N. V. 14207 numoNBi I7S-1S14
PERIODIC HEALTH EXAMINATION REPORT
13. Sacking egor/pipn/cig'li
>
l--
I # pki./doy lot^J J yon
PHYSICAL EXAMINATION
AGEt 54
MUCOUS MEMBRANES (pigment, pallor, naeplasla)
CHEST.
CONTOUR EXPANSION MOBILITY DIAPHRAGMS AUSCULTATION
HEART. Rhythm, rat*, tones, murmurs, B.P.
ABDOMEN. Uv*r/Spl**n
EXTREMITIES. Edema, clubbing, atrophies
NEUROLOGICAL
PCN
TANEOUS
Dermatitis Pigmentation Neoplasia
Examinee's Signature
HEIGHT; ~ P________ WEIGHT. / {p Q ^
'
Signature
/
DTR ADENOPATHIES
M.D.
Anoxia:
Q
P Pulmonale:
Right Heart Strain:
Abnormalities of rhythm:
Abnormalities of conduction:
Other:
ST-T segment changes
BLOOD COUNT
NORMAL
ABNORMALITIES
BLOOD CHEMISTRIES
SMA 12/60: See Attached SERUM ENZYMES:________________________ SERUM ELECTROLYTES: No+ K+ Mg++ SERUM ALPHA I, ANTI TRYPSIN SERUM ELECTROPHORESIS: See Attached
BLOOD LEAD:
MICROGRAMS %
MISCELLANEOUS:
ACHLORHYDRIA (DIAGNEX): OCCULT BLOOD:
URINALYSIS: AL3UM1N___
CHEST XRAY
SUGA
URINE LEAD
(tfoRM/J^
ABNORMAL
MICROGRAMS/UTER URINE SULPHATE RATIO UICC/dNCINNATI
OTHg
Mild prominence of the root areas, few small calcific densities in each. Peripheral lung fields exhibit only minimal increase in broncho-
vascular markings. Heart shadow end bony cage are normal. Chest x-ray is considered to be satisfactory. Attached ventilation study satisfactory Examinee.1 s .overall health status insofar as these studies are concerned. would seem to be quite satisfactory, and present no significant change, from the studies of 1975. Please advise examinee; status would seem satisfactory.
ENVIRONMENTAL DATA: Sampla typa___________ duration
ASBESTOS: Number Fiber, > 5 Mu./Cucm. OTHER: SILICA Mgi./M3
MIC* #.
BU7?AL0 EC5yST22Al IVESICAL CT^H2
7U TOKAWANDA JTEOT
SUFPAIO. N. Y. U307
Telephone E7J-1S14
. H2A5KG 2VAlUAi:OX S'J??LSVUOT
PREPLACEMENT Q_|_
PERIODIC
Cfi05
BASELINE lYwlNol
EXAMINEE:
gMPLQYgg Georgia Pacific
. No,062>18-77?8 , age JOS ASSIGNMENT:
54,
PREVIOUS
DATEt FOR WHOMi
IS PERSONAL PROTECTIVE EQUIPMENT WORN [YeslNoj
hrtiMtl Occupational History: ........... ........... .........
S&YJ3A~0N
hrliMiil Medical Hittoryi.
Allergies-- Hoad injwry.
Singing in Eors_ Mite.___ _____
-Painfwl Can.
.VartigaJUnaing Eon.
Esrs Drums Canal
Noso
R
Military SarvicaPiitini- ,, ..
. Deration-
APPllCANTS EVALUATION OP HEARING STATUS
Normal
3
Nat Normal 0
Canitant 0 Variable 0
Onial
0
Progression
Hat troeble kaaring
la Groups 0
In Aeditoria
In Noiiy Placai 0
At Oitlanca Q
Close 0
Talapbena
Radio.TV 0
Woman and Children 0
Recant# of Ringing in Ran 0
0
Throe? Tuning For*
Dote_______UlUXL
Timet
MtrarrWllM l turn iTieea*.w`M''VesR\L/-v*'*Tk'W*'^R'e Interval since last noise exposure:,
L
A.A.O.O. system. OSHA PROPOSED SYSTEM....
igM Ear Hx
UK far
250
* to
! <,
1000 MOO
/o : "7<r-
. g>
_w_.
vi
__ i__
4000
*000 30
fO sooo to toAVCCACC
T.4. | 4k
AUDIOMETER AM. NAT'l STAND SPEC (ANSI-1969)
AIR BONE
XLIFT
SAK SUIE
oEIGHT EAE
KD
jp-S
REMAEKS ... ^
Examinee's Signature.
Examiner:
// Aj &A'JS>n.a.
"Jir.1,;
N
ig i* -- - -- :-- :-- :-- :-- :-- :-- :-- :-- :-- :-- :-- :-- :-- ^ n o o n ;-- ;-- ;-- ;-- :-- ;-- ;-- :-- ; -- :-- :-- :-- :-- :-- --: .o o ci
flOBEIT -k CA7UTI, MJ vasou> l osaff. mj>. JOHN N. STSACHAN. MJ>.
nami.huMl delies (Wbat 4* |M del
WWi I 0
i* -whh wi *tf>
714 TONAWANDA STMST BUFFALO, N. Y. 14207 mmONi) S7#*1514
PERIODIC HEALTH EXAMINATION REPORT
____________ ____ PATi, 2/23/77_____ inoYH.__CfiQrgia_Eaciic
hwy doy
Hra./doy
days/wk.
awnths/yr.
Froeiee: Mfoiiwi whan -- whea -- ead far bow long Silica -- Mad faendry, aiaiag, qearrying, caraaics Silicate*---tek. oibutoi (type) i aialng, aitiiag, fabrication, application, textiles, other
hri
yon.
INQUIRY
YES
1. Caegh
/
2. Cha> pain
3. SOS al rat!
4. SOS oa affort
5. Expectoration
S. Sleep flat hj.
7. billow* 0 - 1 . 2 - 3 - 6
t. lau wgt./eppetite
9. Increasing fatigue
10. Dysphagia
11. Change in bowel habit
12. Blood lau Cov?h
Vote'll
Bloody itool
Slock itoal
UriM
Skin
13. Samking cigar/pipe/cig'tt ____________________ # pki./doy for________ yeor*
NO
X'
a y
a i t. t i X
X %
PHYSICAL EXAMINATION___________AGE: 61 MUCOUS MEMBRANES (pigment, pallor, neoplasia J
CHEST:
CONTOUR EXPANSION MOBILITY DIAPHRAGMS AUSCULTATION
HEART: Rhythm, rat, tones, murmurs, B.P.
ABDOMEN: Liver/Splaan
EXTREMITIES: Edema, clubbing, atrophies
NEUROLOGICAL
PCN
Cu CANEOUS
Dermatitis Pigmentation ' Neoplasia
Examinee's Signature
.*
HEIGHT;
5* 10" -
WEIGHT: 215
Signature l
DTR ADENOPATHIES
.... M.D.
ELECTROCARDIOGRAM
Anoxia:
Q
P Pulmonale:
Right Heart Strain:
Abnormalities of rhythm:
Abnormalities of conduction:
Other:
NO DIAGNOSTIC ABNORMALITIES ST*T segment changes
BLOOD COUNT
NORMAL
ABNORMALITIES
BLOOD CHEMISTRIES
SMA 12/60: See Attached SERUM ENZYMES:________________________ SERUM ELECTROLYTES: No* K+ Mg++ SERUM ALPHA I, ANTI TRYPSIN SERUM ELECTROPHORESIS: See Attached
BLOOD i Pin.
.............. .......MICROGRAMS /.
MISCELLANEOUS:
ACHLORHYDRIA (DIAGNEX): OCCULT BLOOD:
URINALYSIS: ALBUMIN______ SUG^R--
URINE LEAD.
-MICROGRAMS/UTcR URINE SULPHATE RATIO
%
CHEST XRAY
NORMAL
ABNORMAL
UICC/C1NCINNATI
Mild prominence of both root areas. Some increased bronchovascular markings
in both lower lobes. No evidence of specific parenchymal disease* No evidence
of pleural dysplasia. Lateral projection does demonstrate some increased
radiabilhy behind the sternum. This is essentially unchanged over the pre--
.yIqUjS film.
OTHER
ENVIRONMENTAL DATA: ScmpU type
ASBESTOS: Numbar Fibers > 5 Mu./Cucm. OTHER: S1UCA Mgs./M3
duration
/.tn. a. -jiMMAuv. RTBwIitPP 1b P "orniBl
Ami i timqJVJ >! e
i it:i i j on Inti j ott La a
advise examinee.
~
: DL77A1C IXDUS721ZL J3:CAL C3C72
7U TONAWANDA STIOT
BUFFALO, N. Y. 14207
TnlngWs 073-1514
PREPLACEMENT
K2A22NG EVALUATION SLTO2S2CT
EXAMINES:.
employee Georgia Pacific
_S.S. No.: .111-05-3015 AGE_ 61
JOS ASSIGNMENT:.
PERIODIC
BASELINE Ys | No |
PREVIOUS
DATE. FOR WHOM.
IS PERSONAL PROTECTIVE EQUIPMENT WORN lYilNo
htlianl Occapolionol History: -- -- ... - .
...
exa:,-xat:o.\`
Fartinant Madicol History:.
Allargii_ Naad lnjary_
tinging in EorsMise. ---- ....
Joialul Eon.
_Varligo_ -Banning Eon.
Military Sarvica-
Diilinl
. Deration.
AFFUCANTS EVALUATION OF HEARING STATUS
Normal
0
Not Normal 0
Has trouble Having
Constant 0
Variable 0 Y^#t
Onsat
0
Progrsuion 0
la Creeps 0
in Auditoria 0
In Noisy Fionas 0
At Distance 0
Ciasa 0
Telephone
Rodie-TY 0
Woman and Children 0
tocoaso of tinging in Ears 0
0
Sen Drums Canal
Noso
Throa?
Tuning Fori;
a
Do.., 2/23/77
. Tima:
AIDSC-VJ7TJS SXACT2A7:M
______________ Interval sine* last notsa oxposur*:
Alfto mTM
OSHA FtOPOUD STJTIM_____
tar Vs*
\*tO
Ms . Uft Hr
ISOJ.t.)
soo_
1000 A O :'i
2000 f?S*
L^ra. .JSfP... ^t>j
l-o
4000
<r&
laQ <~s
4000 M00
00 tfn
AVERAGE T.S. in 4b
ao-
AUDIOMETER AM. NAT'l STAND SFEC (ANSI-1969)
AIR
IEFT EAR
RIGHT EAR
XBLUB i oRID
BONE
o
IMAIK&.
sxsmintr:.
L
\
t. ..' jii, m.u.
totetr -a. xaputi, m.o HASOID L GEAW. MJ).
JOHN N. STKACHAN. MLO.
liWl'iAkw iu>'wwintnk iiikiJiWU Wu'liwt
-.
715 TONAWANDA STSSST BUffAlO, N. V. 14207 TUSTHOKEi 575-1514
PERIODIC HEALTH EXAMINATION REPORT
nami.________________ ______________'_______ _^da`_1/26/.22^ :--empioyei,. Gayrgia^-Pacific
--
'(jjt
h'LCJ > ir.fl' D
Every day
Hrtjiwf
ioyi/wk.
month*/yr.
hniMt eaposerei whan -- whan -- and iar haw laag Silica -- sand fovndry, mining, goanying, caramics Silicates -- talc, asbestos (type) i mining, milling, fabrication, application, textiles, othar
fari ^ \ yaon.
INQUIRY
YES
1. Covsh 2. Chait pain 3. SOS at rail 4. SOI an affort 5. Expectoration 4. Sloop flat ha. 7. Pillows 0 1 2 3 S. lots wgl./appatita 9. Increasing fatigue 10. Dysphagia It. Change in bowel habit 12. Siaad lass
Caafh Vomit lloody stool Slack stool Urine Skin
/
13. Smoking cigor/pipe/cig'ts ___________________ # pks./doy for_________yon
NO V
y
c
y
it
V
xV
* V h </ y
Y- % . V
PHYSICAL EXAMINATION
AGE: 61
HEIGHT:
MUCOUS MEMBRANES (pigment, pallor, neoplasia) .
CHEST: CONTOUR
EXPANSION
' -
MOBILITY
DIAPHRAGMS
AUSCULTATION
v` 0
.
: v
WEIGHT: e
HEARTi Rhythm, rata, tones, murmurs, B.P.
ASDOMENi LJvar/Splaan
EXTREMITIES: Edema, dubbing, atrophias
NEUROLOGICAL
PCN
DTR
CUTANEOUS
Dermatitis Pigmontatian Neoplasia
Examinee's Signature
. Signature
ADENOPATHIES
M.D.
F.V.C. =
'TO-try f.ev.,
FEF25%-75% ^,3
IMPRESSION,
NORMAi
IHen/tec.M.V.V. .OBSTRUCTIVE
F. E.V.3 = (Cl) j> \
liton/minute C^RESTRICTIVE ^
ELECTROCARDIOGRAM
.,
Anoxia,
Q
P Pulmonale:
Right Heart Strain,
Abnormalities of rhythm,
Abnormalities of`conduction,
Other,
NO DIAGNOSTIC ABNORMALITIES ST-T segment change*
BLOOD COUNT
NORMAL
ABNORMALITIES
BLOOD CHEMISTRIES
SMA 12/60, See Attached SERUM ENZYMES,________________________ SERUM ELECTROLYTES, No+ K+ Mg++ SERUM ALPHA I, ANTI TRYPSIN_________ SERUM ELECTROPHORESIS, See Attached
BLOOD LEAD,MICROGRAMS %
MISCELLANEOUS, ACHLORHYDRIA (DIAGNEX), OCCULT BLOOD,
URINALYSIS,
ALBUMIN
SUGAR
. URINE LEAD
________ MICROGRAMSAITER
5CHEST XRAY
NORMAL/
ABNORMAL
UICC/CINCINNATI
URINE SULPHATE RATIO
____
%
Mild prominence of the root areas, some general increase in broncho-
vascular markings throughout all lobes. No evidence of specific paren chymal disease. Lateral projection indicates that the diaphragms are smooth and sharp and the sulci are clear. No evidence of significant -----------------radioluc-gney. He-a-rf. sharing and hany nago atp n/vrmal _
OTHER
ENVIRONMENTAL DATA, Sample typo
ASBESTOS, Number Fibert > 5 Mu./Cucm. OTHER, S1UCA Mg./M3
duration
Examinee has no subjective complaints. Ventilation studies siiKgest
& 4,,mIooI root lit I I vo iloTorl , in i 1. 11 v hu ronnot voi- I lie nlmlicn
oi 1
but flow roLcb otherwise satisfactory. Chest x-ray is
satisfactory. Advise examinee of minimal change with regard to ventila
tion study. Otherwise satisfactory-^, Attached aydfergram indicates sig-
nificant bilateral hearing loss,
___ rTM.D.
BUFFALO INDUSTRIAL .VESICAL OJT3
755 TONAWANBA 3TIZZT
WPPALO, N. T. 14307
Tolopbooa (75.1SU
EXAMINEE:
empioym
Georgia
+ Z- /
PREPLACEMENT ^
H2A22KG EVALUATION SUPPLEMVEENNTT
PERIODIC BASELINE lYesINol
Pacific
J&S. No.:. JOB ASSIGNMENT:
A* 61
PREVIOUS
DATE: FOI WHOMi
IS PERSONAL PROTECTIVE EQUIPMENT WORN lYes|No|
Paninant Oaapotionql History:
32
EXA.VRNAT.ON
Parti nan: Msdicol Hhlaqfi.
Ailorgiat. lajary-
Singing in Eon.
Mite.
-,
-Poiafal Con.
-limning Eon-
Military Sarrka. Suliat .-- ..
. Doration.
APPLICANT'S EVALUATION OP HEAIING STATUS
Normal
Q
Not Normal
Constant Variabia Q
Oatat
Pragrattion
hot trawbia haoring
la Ctwpt Q
In Avditorio O
1" Noity Plocat Q
At Dittonca
Goto
Totapbona
Bodio-TV
Woman and Childran Q
Socoata of tinging in Eon Q
Ecrs Drums Ccna!
Noso
Three?
Tuning Fork
RL
r
l/Vi
,Ua.
r !r~
c^y
Date:
64
1/26/77
Time:
______________ Interval sine* last noisa exposure:
PIEOUENCV NEITZ (Hi) g g
^
12S ISO 500 1000
A-A.O.O. STJTIM.
OSHA PlOPOStO YSTIM,,__
tlfht Ear H*
laft Ear
3o
250 A>o
r% Lai
1000 2000 .5000...
An iii
#5 **? Ml i I*''
H 4000
h<r 4000
ro
sooo
J.u
AVERAGE T.S. la 4k
Ar
1
AUDIOMETER AM. NAT'l STAND SPEC (ANSI-1969)
AIS BONE
X LEFT
EAI
SLUE
o rRIGHT
EAR
SED
^
Examinee's Signature:
Examiner:
<5
ry^ c+-*s,s^
UMAIKS.
Q-/ .-j -wT--z-
Of)
<
/ \
ir I \i
I
I
l
M 2i
zo I
Xl
i
i
!
j
Ml
(A
Mlz Ml oo
<
u
<c<mA
i
miZ II
s L:-- :-- :-- :-- :-- :-- :-- :-- :-- :-- -- ;-- ;-- ;-- ;-- p w q o * * -- \-- ;-- ;-- ;-- ;-- ;-- ;-- ;-- ;-- I-- ;-- I-- ;-- ;-- fc o s i
- V. Aim
/.*/.
SOSEIT A.. TAPUTI, LD
HA2310 L 0A, MJ>.
. JOHN N. STtACHAN. MJ.
NAMfi_________________________ frunl dwtiai (Wbot do you do)
WWI I #1% W l$oa. .
. i *t Wtb
d | * V
735 TONAWANDA STRUT BUPM10, N. V. 14307 TBVHONS: 7flJ14
PERIODIC HEALTH EXAMINATION REPORT
.. DATE:. 2/23/77
tMKov. Georgia Pacific
Ivory doy
HwVdoy
dayt/wk.
montht/yr.
hnioai upoiMii wboro -- whan -- ood for bow loog Silico -- sand footidry, mining, quarrying, carnaia Silicalat -- talc, uboilo* (typo) i aining, willing, fabrication, application, tantiloi. other
fori
yoors.
M08IUTY DIAPHRAGMS AUSCULTATION
HEARTt Rhythm, reto, ton**, murmurs, B.P.
ABDOMEN: livor/Sploon
EXTREMITIES: Edoma, clubbing, atrophi**
NEUROLOGICAL
PCN
JTANEOUS
Dermatitis Pigmentation Nooplasia
Exomin**'* Signature
Signature
DTR ADENOPATHIES - * . m .
.M.D.
P Pulmonale: Right Heart Strain: Abnormalities of rhythm: Abnormalities of conduction: Other:
BLOOD COUNT
NORMAL
ABNORMALITIES
BLOOD CHEMISTRIES
SMA 12/60: See Attached SERUM ENZYMES: SERUM ELECTROLYTES: No* K+ Mg+ + SERUM ALPHA I. ANTI TRYPSIN SERUM ELECTROPHORESIS: See Attached
BLOOD LEAD:_____________
MICROGRAMS %
MISCELLANEOUS:
ACHLORHYDRIA (DIAGNEX): OCCULT BLOOD:_____________
URINALYSIS: ALBUMIN___
SUGA
URINE LEAD
MICROGRAMS/UTER URINE SULPHATE RATIO
%
CHEST XRAY
NORMAL
ABNORMAL
1, U1CC/C1NC1NNAT1
Moderate fibrosis of both roots. Moderate fibrosis of all lobes. Some few areas, fibrosis is already is assuming fibronodular properties. Lateral projection Indicates some Increased PA diameter of the chest. No evidence of pleural dysplasia. Compared with #9124, taken 6/75 indicates in essence no -------change.------------------------------------------------------- .--------- --------------------------------------------------------------- ----------------
OTHER
ENVIRONMENTAL DATA: Semple type
ASBESTOS: Number Fiber* > 5 Mu./Cucm. OTHER: SiUCA Mgi./M3
duration
ciimmak:. l*o:i M 1 m I- i imi ai.mUoa vo ouHrolj- iiiiriiial , Cltop I t.rur ia iMn>linni:oil,
itmuh'ic oxiitiiiituL Lott iiulicaluti iiulil bilatwrai iiouriu^; oss jirobubiy 01 acoustic origin. Please advise examinee.
n \ 1
M.D.
BUFFALO L\DUS72IAl MEDICAL C3573
TU TONAWAMSA STIBT
SUFFALO. N. Y. 14307
INopknon 075-1J14
PREPLACEMENT
K2A2ING EVALUATION SU?.^V337
PERIODIC
BASELINE Yes | No]
EXAMINEE:.
___ sa k^.084-24-4603 AQ_46
PREVIOUS
DATE.
.
employes____Georgia Pacific
JOB ASSIGNMENT..
FOR WHOM i
IS PERSONAL PROTECTIVE EQUIPMENT WORN iYeslNo]
Fnrtinanl Occvpotional History.
..... --
EXA.VJMA7rCN
Fortin*Hi Medical History.
Aiinrgias-
iinr-
Singing in EarsMile., ______
-Faint*! I
_Vartlgo_ JUnaing
Military SarvicaOutini--
.Owatiaa
AmiCANT'S EVALUATION OF HEARING STATUS
Normal
Not Normal
CanMant Variabla
Onint
Progression
Hoi trouble kneeing
In Groups O
in Awdiloria
In Noisy Haem
At Oiitancn
dam Q
Tninpkann
Rodio-TV
Woman and Children
ocaase of tinging in tan Q
Ears Drums Canal
Noso
Throat
Tuning Fork
R
L
Date:.
2/23/77
AUDIC.r^TTJC SUT/iNATOnN ______________ Interval since last noise exposure..
FREQUENCY. HERTZ (Hi) # # soo iooo sooo *r & f &
AJL.O.O. ttniu
osma noposio system______
Btht Ear Hs
left Ear
B ?)0
\(Q
250. S'
..."Pm.. ./sri
1000
ir?2000
ns [ YO
1 Ar
4000 *000 1000 AVKRAGC T.5. in db
<7f! pc
AUDIOMETER AM. NAT'L STAND SFEC (ANSI-1969)
Ain OONE
LfET CA2
HUE
V A
RIGHT CAR
RED
O
o
Examinee's Signature. Examiner.
ipoii TL CA7UTI. MJ> Old L GlATf. MJJ.
JOHN N. STKACHAN, MJ>.
V bn' *. o
7*5 TONAWANCA JTKUT SUPPAIO, N. Y. 14307 TBVMOItti B7S-1514
PERIODIC HEALTH EXAMINATION REPORT
name.-------- mr ray ___________ _:--oati.--1/14/Z?---------------------------------tMKOYH.^orgia Pacific
Present Alin (Who* A yon A)
trary day
Mnjday
doys/wk.
OMntht/yr.
hniMi MftMKi wlnn -- whtii-- 4 hr tow Imj Silica -- land foundry, auning, georryiag, ceramic* Silicates -- talc, nbnln (type). orialag, piling, fabrication, application, textile,, other
fort
yeon.
INQUIRY
1. Cough 2. Chott pain 3. SOB at rest 4. SOB an effort S. Expectoration 6. Sloop Rot hj. 7. Pillow* 0 - 1 - 2 - 3 B. leu wgt./appetite 9. Increasing fatigwo 10. Dysphagia 11. Change in bowel habit 13. Stood Iom
Covfh Vomit Bloody (tool Block stool Urino Skin
13. Smoking rigor/pipe/cig't* A, # pki./day for
YES 4-^
/
"J Oyaan
NO
A-"-1
PHYSICAL EXAMINATION
AGE,
MUCOUS MEMBRANES (pigment, poller, naoplosiol
CHEST,
CONTOUR EXPANSION MOBILITY
DIAPHRAGMS AUSCULTATION
'
HEART, Rhythm, rata, tones, murmurs, B.P.
ABDOMEN: Livar/Splaan
EXTREMITIESi Edema, clubbing, atrophias
NEUROLOGICAL
PCN
IU" :OUS Dermatitis Pigmentation Neoplasia
nominee's Signatura
J#'
HEIGHT,
WEIGHT,
Signotura
DTR ADENOPATHIES
_____M.0.
/
P Pulmonale: Right Hoar! Strain: Abnormalities of rhythm: Abnormalities of conduction: Other:
BLOOD COUNT
NORMAL
ABNORMALITIES
BLOOD CHEMISTRIES
SMA 12/60: See Attoched SERUM ENZYMES: SERUM ELECTROLYTES: No+ K+ Mg++ SERUM ALPHA I, ANTI TRYPSIN SERUM ELECTROPHORESIS: See Attached
BLOOD LEAD:_____
.MICROGRAMS %'
MISCELLANEOUS.
ACHLORHYDRIA (DIAGNEX): OCCULT BLOOD:
URINALYSIS: ALBUM!
CHEST XRAY
URINE LEAD. ABNORMAL
MICROGRAMS/LITER URINE SULPHATE RATIO U1CC/C1NCINNATI
%
Mild prominence of the root areas, some calcific densities noted on the
left. Peripheral lung fields generally not remarkable. The lateral pro
jection would suggest some increase in radiolucency behind the sternum,
but this is not grossly abnormal. Heart shadow normal in size. Bony cage
-----------------jnmormaii--Iir essence, liu change "fronr previous "film #6691, taken -10/21/7 f
other
Chest x-ray considered satisfactory for examinee's age. Incidentally, no
evidence of pleural dysplasia.
ENVIRONMENTAL DATA: Somplo typo
ASBESTOS: Number Fibers > 5 Mu./Cucm. OTHER: SILICA Mgs./MJ
duration
misc & summary* History of some shortness of breath noted. Studies include only ` ventilation and chest x-ray,are both noted to be satisfactory and compared favorably with the previous studies. Audiometric examina
tion likewise satisfactory. Please advise examinee.
___ M.D.
BUFFALO INDUSTRIAL r.'^RICAL CZKZ1
7M TONAWANDA STUR
EUrFALO. N. Y. 14307
Tafepbeaa S7S-1514
KEA&NG EVALUA720K Sy??LSV3.7
PREPLACEMENT
PERIODIC
BASELINE lYeTf No]
EXAMINEE:
S.S. No., 11.2-12-6442age__59_
PREVIOUS
DATE,
O
employed Georgia Pacific
JOE ASSIGNMENT,.
FOS WHOM:
IS PERSONAL PROTECTIVE EQUIPMENT WORN lYesINol
Partisan, Occapatloaol Hitloryi.
EXArVJXAwOM
Partisan, Modical History i.
Ailorgiot-
Isirf_
Singing in EarsMisc. ______
-Points! Ian.
.Vsrtigau. -loaning Ears-
Military Ssnrita-
. Dsroiioa-
APPLICANT'S (VALUATION OP MCAIING STATUS
Norma]
Q
No, Normal
Hat trouble hearing
In Aadilorio A, Dittonta
Ye No
Constant VortaWa Q
In Noiay Plocoi Ooto Q
OnM,
Progrsttion Q
la Croapt Q
Talaphona Q
todio-TV Q
Woman and Children Q
Sacaaao a. Singing ia Can
Tr.roct
Tuning Fork
Dot:
1/14/77
Tim*,
AUDJQfclSTZC ESiUZCATOM
.Interval sine* last noisa exposure:
FREQUENCY - HEST2 (Hz)
1
_______1_______
J' ! ~r
K /am
f
7
o
N\ *
N
uau z 1r
to
yfu Cr,xd llnlnn j
' J/ V7>|
A.A.O.O. nmiu OSHA PIOPOSED SYSTEM____
Uflht Car Hi
LaH Ear
(C
ISO
<-* 1
t...VP...
5 / S ,000 7 1
I * 2000 0 i
LXCa. _00_
o/ 4000 ID
td 4000 l\
/ c seoo if
JJL AVCKAOC T.$. in 4b
u
AUDIOMETER AM. NATU STAND SPEC (ANSI-1969)
AIR BONE
LEFT EAR UUE
V/ V
oEIGHT EAR
RED
o
Examinee's Signature, examiner,.
OOSi
rO S IT jO N TH IS EDGE NEAREST CABINET
t
i.'AMOUk. M.O. SOSEJtT A. CAPUTI, M.O MASOIO L. OKA. MU>. ' JOHN N. STKACHAN, M.O.
4
KAMI.___________________ Mml Satina (Whol do you 4m}
OWiVJWVJ
uikWlWW WMOMk
7SS TONAWANDA STIHT BUFFALO, N. Y. 14207 TBmONIi S75-1414
PERIODIC HEALTH EXAMINATION REPORT
hat. 2o 10/77iMPtoYSBt Georgia Pacific
fvery Joy_____________________Kr./doy
deyi/wk.
awntha/yr.
Pnrriaea expoavrai where -- when -- mm4 far haw tang Silica -- road laundry, aiaing, georryiag, caroaica SliicoMt -- tok, aabeatoa (typa)i aiaing, Billing, fabrication, application, tactile!, other
fori_______________yon.
INQUIIY
YES
1. Cough
2. Cheat pain 3. SOS ot rail 4. SOS on effort
5. Ecpectoretion
6. Sleep Sat k4. 7. Pillow! 0 1 2 3 -
1. let! wgt./appelite
9. Increating fatigue 10. Oyaphagia
11. Change in bowel habit 12. Stood leal
Coegh Vomit
iloody itoei
Slock itool
Urine
Skin
13. looking ciger/pipe/cig't* ____________________ # pka./dey for________ yaora
NO
i/a
Jl/(?
V/ /
J J
7
J
4
/
Jh
7/
PHYSICAL EXAMINATION___________AGE. 60________ HEIGHT; 5*7"_________WEIGHT,
MUCOUS MEMBRANES (pigment, pallor, neoplasia). - .
15Q
CHESTt
CONTOUR EXPANSION ; MOBILITY DIAPHRAGMS AUSCULTATION
A
HEART, Rhythm, rota, tonas, murmurs, B.P.
ABDOMEN: Liver/Spleen
EXTREMITIES, Edama, clubbing, atrophias
NEUROLOGICAL
PCN
OTR
ANEOUS
Dermatitis Pigmentation
Neoplasia
Examinee's Signature
' Signature
ADENOPATHIES ...
P Pulmonale: Right Heart Strain.Abnormalities of rhythm: Abnormalities of conduction Othen
BLOOD COUNT
NORMAL
ABNORMALITIES
BLOOD CHEMISTRIES
SMA 12/60: See Attached SERUM ENZYMES: SERUM ELECTROLYTES: Na+ K+ Mg++ SERUM ALPHA I, ANTI TRYPSIN SERUM ELECTROPHORESIS: See Attached
BLOOD LEAD:
MICROGRAMS %
MISCELLANEOUS:
ACHLORHYDRIA (DIAGNEX): OCCULT BLOOD:
URINALYSIS: ALBUMIN___
CHEST XRAY.
SUGA
URINE LEAD
NORMAL
ABNORMAL
MICROGRAMS/UTER URINE SULPHATE RATIO , UICC/CINCINNATI
%
Mild prominence of both root areas. Some increased radiability in both uppers,
and in the left base.Lateral projection Indicates increased radiability behind the heart and behind the sternum. Diaphragms are flat and in the lateral proj ection. Chest x-ray suggests pulmonary emphysema of a modest degree and in --essence' hS~bhgBge "from previous film -#9019~ taken-10/30/73.-----------------------------------------
OTHER
ENVIRONMENTAL DATA: Somplc type
ASBESTOS: Number Fibers > 5 Mu./Cucm. OTHER: SILICA Mgs./M3
duration
F>ntni.npe has evidence of mild pulmonary emphysema, essentially un-
/ *> onfWfn..
jt i;t| |(y
Vm4-I t 4> I
I i.o
**.*? 4- tin. | i
n |'
iiulli obstructive and restrictivo delect. Again oasoniially uutdtaiuMid i: >< in>;
previous studies. Please advise examinee he does have pulmonarv^einphysema al
though not disabling. Incidentally, studies of the chest does hot demonstrate
the presence of any pleural dysplasia. Attached audiogram demonstrates moderat*
'"Hnr. loss of a sensori-neurol variety.
... ~ .. ^..... --\------------ .------
-------------------. > i'
: SUSvALO INDUS7KLU E3XCAL C5KZ2
7U TONAWANSA STUET
EUPPAIO. N. Y. 14207
Talapfcan S75-1S14
EXAMINEE:.
PAiPinvgB
KIATJNG EVALUATION SUPPLSVS^
PREPLACEMENT PERIODIC BASELINE Yes No]
-S.S. No.s.
.AGE. 60
PREVIOUS
DATE:
Georgia Pacific
J03 ASSIGNMENT:
POt WHOM.
IS PERSONAL PROTECTIVE EQUIPMENT WORN lYeslNo
Partiaaat Occapolianol Hitloryi
..
SULVJSCATSCN
hniaml Madteal HiMaryt.
Aliargint___ Hood lajvry_
tinging in an._ Mite. --...........
-Painful Ewi.
_Vertigo-tanning Eon-.
Military SarvicaOutiaa--------------
. Dwatian-
APPUCANTS EVALUATION OP HIAtING STATUS
Normal
0
Nai Normal 0
Conttant 0 Variable 0
Onto!
0
Progression 0
Hai trouble hearing
la Groups 0
la Aaditoria 0
In Noisy Placet 0
At Distance 0
Claw 0
Telephone
Kadia-TV 0
Women and Children 0
lacoata of tinging in Eon 0
0
Sara Drums Canal
Nos
Thrcct
Tu.'.Ir.g Tori
g
L
Date:
2/10/77
Time:
AUDIDaVaTOIS ______ Interval since last noise exposure:
PIEQUEiNCY HEtTZ (Hx) g g ^
123 >30 300 tooo
t:sc'
`r
1
!___ i
-iloi i!
f
1 V i----d
r\ V
___1
\f r
5 I _1
> \\
: ( 45V
V
jSSfcJ ..
iiA
1j
/ 'A
/UrJli at AefsrwJa'
J lllti
AA.O.O. SYSTEM. OSHA PCOPOSEO SYSTIm______
tight tar Ks
Laft Ur
jr"
\Qo \ j>y.
230
1000 2000
?<-; "3 Tl
`T^l
o ^ ;i
L-? *
.."Q.i
ii
4000
no
n*T, 4000
n<i
1000 ni
-211
AVItAGt T.S. in 4b
3L--
AUDIOMETE2 AM. NAT'l STAND SPEC (ANSI-1909)
All? BONE
liPT EAR IIGHT CAR
SLUE RED
V /\
o
V_'
Examinee's Signature: Examiner:___
t J
... > '
. . ~>.J.
tOtclT A. CAPUTI. MJ>
HAtOlO L OCAPP, M.D.
JOHN H. STIACMAN, *U5
NAME._________________________ Prasonl duliH (Whot do you dot
WWi'I'AkU iaWV4<<>^ <n*/iWW
Mi
PM TONAWANOA STEEIT
SUFPAIO, N. r. 14207
TUPHOMS. E75-1S14
PSUODIC HEALTH EXAMINATION REPORT
2/23/77 mupy,,. . Georgia Pacific
OATEi.
Erary day
Hnjday
days/wk.
ateaths/yr.
Previa*. upturn where -- when -- mod ter bow teas Silica -- land foundry, mining, g*orryi*g, ceramics Silicatet -- talc, uteitM (type) aiaios, miUiag, fabrication, application, teililu, olhar
loti
yuan.
INQUItY
YES
1. CdvQh
2. Chait pain
3. SOS ot rail
4. SOt on effort
5. Expectoration
6. Steap tat h.. 7. Pillow* 0 1 2 3 -
/
1. Lou wgt./appatita
9. Inertoting fotigwa
10. Oytphogio
11. Chang* in bowel habit
12. Stead *ou Coufh
Vomit bloody .tool
black steal
Urin*
Skin
13. Sowkiag cisor/pipa/eig'r ________________ / # pks./doy for JbO years
NO y
X
1
tS"
f/ i/ S'
S' s S'
s s
PHYSICAL EXAMINATION
AGE. 49
MUCOUS MEMBRANES (pigment, pallor, neoplasia `
CHEST.- CONTOUR . EXPANSION MOBILITY DIAPHRAGMS AUSCULTATION
HEIGHT. -
5 * 10"
. -c *'
WEIGHT. 150
. w"r. - *
. * **
. * "4 .
\
* 0.
' s w
nj -f
a
HEART. Rhythm, rat*, tones, murmurs, B.P.
ABDOMEN: liver/Spleen
EXTREMITIES. Edema, dubbing, atrophies
NEUROLOGICAL
C MEOUS Dermatitis 1 Pigmentation Neoplasia
Examinee's Signature
*
*
PCN ` % *
4
* ?
Signatun> ~
-
..
>| to
DTR
ADENOPATHIES ' 5 - , *'*
* . . ** w' v* *
!. 1 aa
*. 2 .
.%.**
*
. * a ,
b
... M.D.
P Pulmonale: Right Heart Strain: Abnormalities of rhythm: Abnormalities of conduction: Other:
BLOOD COUNT
NORMAL
ABNORMALITIES
BLOOD CHEMISTRIES
SMA 72/60.- See Attached_________________ SERUM ENZYMES:________________________ SERUM ELECTROLYTES: No+ K+ Mg+ + SERUM ALPHA I, ANTI TRYPSIN_________ SERUM ELECTROPHORESIS: See Attached
BLOOD LEAD:MICROGRAMS %
MISCELLANEOUS: ACHLORHYDRIA (DIAGNEX): OCCULT BLOOD:
URINALYSIS: ALBUMIN______ SUGAR_____
URINE LEAD
________ MICROGRAMSAITER
CHEST XRAY j33 T NORMAL
ABNORMAL.
UICC/CINCINNATI
URINE SULPHATE RATIO
%
SLt. fibrosts of both roots. There is evidence of pleural thickening at the
summit of each lung, probably as indicative of old inflammatory disease. No evidence of specific active disease however. Heart shadow, bony cage are nrml. This film compared with #9018 taken 10/75 indicates in essence no change.
OTHER
ENVIRONMENTAL DATA: Semple typo
duration
ASBESTOS: Number Fibers > 5 Mu./Cucm. OTHER: SIUCA Mfl./M3
:u t
Ventilation study at this time although satisfactory, does indicate
Mll*t ttltltlw ( | mi i u Mtd liit'iidil r l I'M I
I'.V iinil lint nuiI inmii
iii'outning capacity, as couipai*ed to the eurlior study. Chesc-Xrruy is un
changed. Audiometric examination indicates the presence /& mird bilateral
heating loss. Examinee's status in general atmmkra t.a ha nncWfAd .
advise
\Tt--
v
.M.D.
BUFFALO INDUSTRIAL I3SICAL CSC7S2
7U TOMAWANDA STEEZT
BUFFALO, N. T. 14307
TnlnpfcoM S7S-M14
EXAMINEE:.
. K5ARIMG EVALUATE SUPPl&ViStf
103-24-3225
49
-S.5. No.:.
. AGE-
employer------- Georgia -Pacific
JOB ASSIGNMENT:.
PREPLACEMENT
PERIODIC
BASELINE YeTT No]
PREVIOUS
OATEi FO WHOM.
IS PERSONAL PROTECTIVE EQUIPMENT WORN [Yes [No
totinnl Occupational Hulotyi. -- - ---, -
-
2XA.VJXA7JCM
httinnt Mndicol Hiitory I.
Allnrgint___ Head Injury-
tinging in CanMite. --------,,
-Painfvl Can.
-Vnrtigo-Inning Eon--
Military SorvicaOutint .....
.Duration-
APPLICANT'S IVAIUATION OP HIAEING STATUS
Normal
Q
Nat Normal
Caaitant Q Variobla Q
Ontnl
Pngnttian Q
'at troubln hoaring
In Graupt Q
in Auditaria O
I* Natty Placat
At Oitlancn Q
data Q
Tnlnphono
Eadia-TY
Wanna and Children
Bacauta al tinging in Can Q
Q
Ears Drums Canal
Neso
Throe?
Tuning Fork
R
L
AUDiaaSETZC
Date:
64
2/23/77
. Tima:
______________ Intarval tinea Iasi noita axpoturai
PtEOUENCY - Him (Hi)
////123
250
too
1000
2000
11
!
3 J. 2j 8J
-
________ . Y
II ymimm i . 1
* * V\ .* J \vl/
1
\
osna peoposed mu_____ i
*ibt (nr
(Ju
by p6
Ht ISO 500 1000
O 7000
.2000
UHEnr 1 tlO 1
ss
*^i! a,c2.J
i J..
1
y*
4000
0 J?
/V> -V.cJ Arm 'Z HZli Si/sW Unina '
(yllriU >
&
NV
-/j
tk
/
>
V
a
mm
6000 WOO AVERAGE T.S. In 4b
AUDIOMETER AM. NAT'l STAND SPEC (ANSI-1909)
Alt BONE
LEFT EAR
SIGHT EAt
tUIE M0
/N O
/s
Examinaa's Signoturai. Exominar:_______ __
rZL<L_^
r ' *n TMi? r'C*r i<c;Rrf c p*nct
i . /* : j\t EY.O. . , iOEtSl A. CAPUTl, MJ>
HASOLD L 6IAEF, M.D. JOHN N. STIACHAN. MJ>.
NAME.
___________________
Emaol dta (What da yon da)
WWIOk^
|i
7U TONAWANOA STSSST SUffJUO, N. Y. 14307 lUBHONSt S7S.1514
PERIODIC HEALTH EXAMINATION REPORT
-Date, 1/14/77employe!. Georgia Pacific
Srary day
HrVdoy
dayt/wk,
Montht/yr,
Eraviavi aapotvrai wham -- wbaa --- and far haw laag SSica -- sand (avndry, ariaiag, gaarryiag, caraaks Silicstst -- talc, aibattot (typa)i auaiag. Milling, fabrication, application, textile:, other
far.
yen.
13. Saaokiag cigar/pipo/cig'ta ____________________ # plu./doy for________ ynort
PHYSICAL EXAMINATION
AGE:
Ma UCOUS MEMBRANES (pigmant, pallor, naoplosia)
CHEST:
CONTOUR EXPANSION MOBILITY . DIAPHRAGMS AUSCULTATION
*
HEIGHT:
HEART: Rhythm, rat*, ton*s, murmur*, B.P.
ABDOMEN: Liv*r/Spl**n
EXTREMITIES: Edams, dubbing, atrophias
NEUROLOGICAL
PCN
i'ANEOUS
Darmatitis Pigmsntation
................
WEIGHT: . . ' .......-
DTR ADENOPATHIES
P Pulmonale: Sight Heart Strain: Abnormalities of rhythm: Abnormalitios of conduction: Other:
BLOOD COUNT
NORMAL
ABNORMALITIES
BLOOD CHEMISTRIES
SMA 12/60: See Attached SERUM ENZYMES: SERUM ELECTROLYTES: Na+ K+ Mg++ SERUM ALPHA I, ANTI TRYPSIN SERUM ELECTROPHORESIS: See Attached
BLOOD LEAD:_______
MICROGRAMS %
MISCELLANEOUS:
ACHLORHYDRIA (DIAGNEX): OCCULT BLOOD:
URINALYSIS: ALBUMIN___
SUGAR
URINE LEAD
MICROGRAMS/UTER URINE SULPHATE RATIO
%
CHEST XRAY S~{ {/L-" NORMAL
ABNORMAL
UICC/C1NC1NNAT1
other
Mild prominence of the root areas, minimal increase in bronchovascular markings over the lower halves of both lung fields. Trachea in midline. Lateral projection does not demonstrate flattening of the diaphragms. Heart shadow has some broadening in the region of the thoracic aorta. The bony cage is not remarkable. No evidence of pleural dysplasia noted. Uiest x-ray is considered to be satisfactory for examinee's age ana compared with #8890, taken 10/21/75, in essence, no change.
ENVIRONMENTAL DATA: Somplo typo
duration
ASBESTOS: Number Fiber* > 5 Mu./Cucm. OTHER: SILICA Mgt./M3
Ventilation studies, chest x-ray are both satisfactory and essenmisc & summary: tially unaltered. Audiometric examination-is satisfactory. Please
note, no other studies done.
DUIvALO U\SDUS72iAL .ViB.'CAl
7U TONAWANDA IT2ST
SUMALO. a Y. 14307
Tolopkaao S7S-1S14
EXAMINEE: employer,
PREPLACEMENT O
VSASDiG SVALUA7!OM SU7P13&X?
PERIODIC
BASELINE [Tel] No]
Georgia-Pacific
-S.S. No.:. JOE ASSIGNMENT:
.ACE. 60
PREVIOUS
OATCt FOR WHOM:
IS PERSONAL PROTECTIVE EQUIPMENT WORN I Yet No |
hrtiMal Ottwpolioaal Hiiloryi. - --*
. ...
hoiitnl AMIcal Hiiloryi.
Allrgiat__ Head lojury-
Ringing in Ean_ Mite. ......... ..
-Painful Ear*.
.Vartiga.tvaaiag Core.
Military SorvicaDgiai_______
. Duration-
APPIICANT'S EVAIUATION OP HEAI1NG STATUS
Normal
0
Not Normal
Caution: 0 Variable
Oniel
Progreuioa 0
Hat trouble hearing
la Group* 0
la Audiloria 0
la Noiiy Plocet 0
At Oiitanco 0
Oom Q
Telephone
Rodio>TY 0
Womaa and Ckildraa Q
Sacauta at tinging i* Can 0
0
Ears Drums Canal
Ncso
Throat
Tunir.3 ?orlc
R
Data:
1/14/77
. Tim*:
AUDIOrrUaiiiMC
llWu'u
______________ Interval sine* last noise exposure:
L
Examiner:
i.i t. AMUOK, MJ). SOIEn* A. CA7UTI. MJ) HAdO?C L OlAff, MJ). JOHN N: STSACHAN, MJ).
NAME._________________________ haiMt Min (Wkal M yen Jo)
.MOliribV *1 IV W >r > IMI tb
11 .
TU TONAWANDA STUET MJffALO, N. Y. 14207 mVHONSi S7S-1S14
PERIODIC HEALTH EXAMINATION REPOST
QATi. 2/10/77 Emw.oYEa.G6orgia Pacific
Erery doy
Hrs./doy
deys/wk.
months/yr.
Stamens aapesure. where -- when -- and far hew long Silica -- (and foundry, mining, quarrying, ceramics Silicatai -- talc. asbestos (typo) i mining. milling, fabrication, application, tutilas, atkar
far.
yaan.
INOUitY
1. Cough 2. Chut pain 3. SOS at rut 4. SOS on effort 5. Enpectoration 6. Sleep Hat h.i. 7. ffillows 0 1 - 2 - 3 S. Iasi wgt./appetite 9. Increasing fatigue 10. Dysphagia 11. Chang# in bowtl habit 12. Wood loss
Covfh Vomit Siaady stool lack steal Urine Skin 13. Smoking cigar/pipo/cig'to _______________ f jr. # pks./doy for
YES
s~ 1
no years
NO/' / s' '
/
V y
/ y
//
PHYSICAL EXAMINATION
AGE; ^9________ HEIGHT: VS"
WEIGHT:
MUCOUS MEMBRANES (pigment, pallor, iMopiatia)
-.
CHEST.
CONTOUR EXPANSION MOBILITY DIAPHRAGMS AUSCULTATION
HEART. Rhythm, rata, tonas, murmurs, B.P.
ABDOMEN: Livar/Splaan
EXTREMITIES. Edama, clubbing, atrophias
NEUROLOGICAL
PCN
OTR
.fANEOUS
Dermatitis Pigmentation Neoplasia
Examinee's Signature
*
Signature
ADENOPATHIES
Right Heart Strain: Abnormalities of rhythm: Abnormalities of conduction: Other:
BLOOD COUNT
NORMAL
ABNORMALITIES
BLOOD CHEMISTRIES
SMA 12/60: See Attached SERUM ENZYMES: SERUM ELECTROLYTES: No+ K+ Mg++ SERUM ALPHA I, ANTI TRYPSIN SERUM ELECTROPHORESIS: See Attached
SLOOP LEAD:
MirarviPAUc %
MISCELLANEOUS:
ACHLORHYDRIA (D1AGNEX): OCCULT BLOOD:
URINALYSIS:
ALBUMIN______ SUGAR_____ __ -.URINE LEAD
-------------- ---
CHEST XRA'fSJ'/' `ifFORMAL /
ABNORMAL
MICROGRAMS/LITER URINE SULPHATE RATIO UICC/CINC1NNATI
%
Mild prominer^e_j>^the root areas. Peripheral lung fields generally not re markable. Trachea is inmidline. Diaphragms are smooth and all sulci are clear. There is some very equivocal evidence of pleural dysplasia along the left par ietal border. It is not marked. Heart shadow, bony cage are normal. Chest x-ray should be considered satisfactory.
OTHER
ENVIRONMENTAL DATA: SompU typo
ASBESTOS: Number Fiber* > j Mu./Cucm. OTHER: SILICA Mgs./M3
duration
lie . cti/wi-n,.
PMne ifl Ml -rP*rnr|1 t;n t-lio (lino I T--r"V Mini VPIlt I In I'I mi pi ml tup
i.ii In:
l'Lt:>i>i: <uiv I ><. Ami | ii.ni|.r I ii t Lmiy <i
at this tine is quite satisfactory.
DUlvALO IXDUST^AL iV^DiCAL CEOT2
TU TONAWAM8A ST3BT
BUFFALO. N. Y. 14207
Telephone
EXAMINEE:. employed
Georgia Pacific
fwimt Occupational History, - -
- ....
PREPLACEMENT
PERIODIC
BASELINE Yes | No I
_S^. No.t JOB ASSIGNMENT,
age 49
_ PREVIOUS
DATE, FOB WHOM,
O
IS PERSONAL PROTECTIVE EQUIPMENT WORN | Yes No
BCAtYJKATiGN
hflinMl Medical History,.
Allergiet--_ Head Injury.
Binging in fan. Mite......... --
-Painful fan.
.Vertigo. .tunning Eart_
Military ServiceDuties--______
APPLICANTS EVALUATION OP HEABING STATUS
Normal
Q
Not Normal
Hat trouble bnaring
Cautanl
Vanallin Vat
Q Q
Omni
Q
Progrnttion Q
In Groups
In Auditoria C
In Natty Placet
At Distance Q
Ciotn
Telephone
Sabia-TV Q
Woman and Childran Q
Socauta of Binging in ion Q
Q
Sars Drums Cana!
Koso
Throe}
Tunip.o rork
R
L
Date:
i
!.
L.
Uaui
j. S
2.10.77
. Time:
Ai&mz?tjc
______ Interval sine* lost noiso txposurtt
PBEOUENCY HEBTZ (Hi)
12s
330
300
1000
2000
i i ii
I Xk
N
..j /- /
i rr /
! ' >
' i
"rrr l
V 1 nT ,1 V
i
\ /Y
(
V.
/
j
AAOO imm
OSHA PROPOSED SYSTSM.____
Eight Ear Hs
Uft Ear
10 250
. 300, 3& 1
sH* 1000
'S. 3000
LSi.. 3000
uo /s4000
i
mSAAu SmUUn.'B.Mv%i {
l/l'Sj cf
j
1
m.
/Q
JO
*000 /ti SOOO
AVERAGE 'itH
T.S. In 4b
AUDIOMETER AM. NATL STAND SPEC (ANSI-1969)
AIR CONE
x !LIPT
EAt
SLUE
OSIGHT EAS UD i
|O
Examinee's Signature*.. Examiner:____________
/
eo*^wwrr
400M L
PO SITIO N TH IS EDGE NEAREST C ABIN ET
i . 4w v
(OCrtT CAPUT), M.D HASOLO L OSAPP, MJ>. JOHN N. STSACHAN, MJ>.
MAMti_____ _________________ html Julin (What da yo do)
WWKXkv <10.0.. . <o -- -- #
wamul
713 TONAWANOA STUIT MIPPAJLO, N. Y. 14207 TBXPHONb S7S-1S14
PERIODIC HEALTH EXAMINATION RB>ORT
pati. 2/23/77 iMHora,--Georgia Pacific
leery day_____________________ Hcs./doy
days/wk-
esonths/yr.
freeiou: exposure. where -- when -- sad tar haw long Silica --sand foundry, mining. geonylng, anaki Silicates -- tolc, asbestos (typo) mining, milling, fabrication, application, textiles, ether
fan
yon.
INQUIRY
| YtS
1. Cough 2. Cheil pain 3. SOS al ml 4. SOS on effort S. Enpectorotion 4. Sleep Set h.i. 7. Pillow: 0 1 - 2 3 S. La:: wgt./oppetite 9. Increasing fatigue 10. Dysphagia It. Change in bawd habit
12. lloeC loss Cough Vomit Woody stool lack stool Urine Skin
13. Soaking dgor/pipe/cig'tt ____________________ # phi./day far________ yean
NO M) lA/0
jyt W. /w>
AS? fin /t/zr tl/o /w We
/yz
PHYSICAL EXAMINATION__________ AGEi 50_________ HEIGHT: 5*11*'
MUCOUS MEMBRANES (pigment, pallor, nooplasia)
WEIGHT, 235
CHEST:
CONTOUR EXPANSION MOBILITY DIAPHRAGMS AUSCULTATION
HEART: Rhythm, rota, tonas, murmurs, B.P.
ABDOMEN: Livar/Splaan
EXTREMITIES: Edama, clubbing, atrophias
NEUROLOGICAL
CU~' NEOUS
Dermatitis
Pigmentation Neoplasia
Examinee's Signature
PCN
Signature
OTR ADENOPATHIES
P Pulmonale: Right Heart Strain: Abnormalities of rhythm: Abnormalities of conduction: Other:
BLOOD COUNT
NORMAL
ABNORMALITIES
BLOOD CHEMISTRIES
SMA 12/60: See Attached SERUM ENZYMES:________________________ SERUM ELECTROLYTES: Nc+ K+ Mg++ SERUM ALPHA !r ANTI TRYPSIN SERUM ELECTROPHORESIS: See Attached
BLOOD P*n.
MICROGRAMS %
MISCELLANEOUS:
ACHLORHYDRIA (DIAGNEX): OCCULT BLOOD:
URINALYSIS: ALBUMIN___
SUGA
URINE LEAD
CHEST XRAY^yj^ NORMAL
ABNORMAL
MICROGRAMS/UTER URINE SULPHATE RATIO UICC/C1NCINNATI
%
Moderate fibrosis of botb roots and all lobes. Some few areas, fibrosis is beginning to exhibit flbronodular characteristics which is generally re flecting examinee's body build. Heart shadow, bony cage are nrml. Very min imal Increase in peripheral fibrosis as compared to previous film #9125, -------takes--11/6/75,------------------------------------------ -----------------------------------------------------------------------------------
OTHER
ENVIRONMENTAL DATA: Sompla type___________ duration
ASBESTOS: Number Fibers > 5 Mu./Cucm. OTHER: SIUCA Mgs./M3
Ml ' 6
Vntilnt.ion *t,tidy qnl t* eit iofnotory, !u fact pnmowlint.
nvor
1 |,jlo u l.utly uf J*//5. `liooL
(lonol'al ly inti. loom i It c* I I u. Ii* uvlili.m.u
of ploural dysplasia, which would suggest uuy asbestos exposure, rlcusu ad
vise examinee.
M.D.
BU77ALG INDUSTRIAL .VJDICAL C2N72
7SS TONAWANDA XTUZT
SUFFALO, N. Y. U307
Tatopkaae SW-liU
EXAMINEE:.
PMPinvgg
PREPLACEMENT
K2ATJXG SVAUJATJCM Si5??:
PERIODIC
BASELINE Yes | Nol
___u. No., 106-20-2676 AGE_S0
PREVIOUS
DATE:
Georgia Pacific
JOB ASSIGNMENT,.
FOR WHOM.
IS PERSONAL PROTECTIVE EQUIPMENT WORN I Yes I No |
Miiml Occwpotiaaal Hiltary,
. ... --...... *..
Partinaal MHiui Hidary:.
Allorgia-__ Hied Injury-
Ringing ia Eort_ Mile___________
-Paiafal Eon.
.Vwliga. JUaaing Ean_
Scrs Drums Canal
Noso
R
L
Military SarvicaDuliai--___
. Daretiaa-
APPLICANT'S EVALUATION OP HEASING STATUS
Normal
Q
Nol Narmal Q
a, troubla haoring
Gaaitant
VaraMa Yat
O
Oniat
Q
Prograuiaa Q
la Graapi O
in Aadilario Q At Oiitanca Radio-TV
la Naiiy Plocas
Ciaia
Tatopkono
Weaioa aad Childran Q
Q
Saeaaia of liaging ia Eon Q
Throe? Tuning Fork
Date:____ 2/23/77
'
XVZ' .
t:s p1
!i i:>
-"c!i_____ I
2 J1
!
L*/,
toVJ OL
i-
CU>i O
i
i .. i
-
i/> --
o
ass
J X
'
^^Ana<jg |A l li'.tcj tua'aii ^ I/' cl Ar^icwhr!
A | ra/>aar*^aa rnt a4lni^aWaUi*i4*'i
y^Wyv
. Time:
.Interval since last noise exposure,
FIEOUBi4CY. HECTZ (Hx) g g g
500 1000
1" 1.
~n
a a n o irmy ]OSHA POOPOSED SYSTEM______
p-------
r '1
<_ t %
/
ftitbt Ur Hx Ufl Ur |
/ 0 250 7?F]
nrr1 l)
1000 "l"1 2000
_____ ______
\WM7 WK.
jl
ixS~.
fO
to . 4000 ir 1000
/S'
(a,(a ATV.C.RinAGtCt
AUDIOMETER AM. NAT'L STAND SPEC (ANSI-1969)
AIR BONE
uCAnR UUE 1i /V RCIGAHRT EEO { O
Examinee's Signature: Examiner:
4
7400 ML
PO SITIO N TH IS EDGE NEAREST C ABIN ET
.
n, M.O.
OSUT A. CAftlTI, M.D
HAtOlO L ClAff, M.D.
iQHN W. STtACHAN. MJ>.
NAMIi_________________________ frvwnt <iIm (Whot do ye* <)
MVI1
it v . i (ttrift 11lu/iiaAft Wfti 11n
745 TONAWANDA STtllT MJKAIO, H. Y. 14307 THJPHONI: 474*1414
PERIODIC HEALTH EXAMINATION REPORT
axT. 2/10/77
mnoYi.1 Georgia Pacific
trtry aoy_____________________ WrVday
dayi/wk.
aonthc/yr.
hniMi upeum wlwra -- whan -- and tar haw long Silica -- tend foundry, aining, gaarryiag. araaici Sidcotai -- talc, asfcaitoi (type) i aiaiag, aiding. fabrication, application, taatilai, other
fori
y*at.
13. Soaking cigar/pipe/cig'li
/ A/f
#phi./4ayfoc
rwn
PHYSICAL EXAMINATION__________ AGE.
__________ HEIGHT: 5* 7"_________WEIGHT:
MUCOUS MEMBRANES (pigment, pallor, naoplasio)
^0
CHEST.
CONTOUR EXPANSION MOBILITY DIAPHRAGMS AUSCULTATION
HEART: Rhythm, rota, tonas, murmurs, B.P.
ABDOMEN: livar/Spiaon
EXTREMITIES: Edama, dubbing, atrophias
NEUROLOGICAL
TANEOUS Dormaiiiit Ncoplaiia
Examinee's Signature
PCN
. Signature
DTR ADENOPATHIES
7 *
M.D.
P Pulmonale: Right Heart Strain: Abnormalities of rhythm: Abnormalities of conduction: Other:
81000 COUNT
NORMAL
ABNORMALITIES
BLOOD CHEMISTRIES
SMA 12/60: See Attached SERUM ENZYMES: SERUM ELECTROLYTES: No+ K+ Mg++ SERUM ALPHA I, ANTI TRYPSIN SERUM ELECTROPHORESIS: See Attached
BLOOD LEAD:
MICROGRAMS V.
MISCELLANEOUS:
ACHLORHYDRIA (DIAGNEX): OCCULT BLOOD:
URINALYSIS:
A----L---B---U---M-----I-N---_---_--_---_--_---_ --SU--GArR_____
URINE LEAD
________ MICROGRAMS/UTER
CHEST XrayJ^V NORMAL
ABNORMAL
UICC/CINCINNAT1
URINE SULPHATE RATIO
%
Mild fibrosis of both roots. Moderate fibrosis of all lobes. Multiple snail calcific densities in each. Some evidence of pleural thickening at the summit of each lung. Heart shadow although rather full, is not abnormally su. Later
projection demonstrates a distinct increase in the PA diameter of the chest
w/se=>3~gl-attening-of the- diaphragm. longossioa -that -early--pu__l___ > *> T-ir 1 rj OTHEcRR' _ap rocbeamoolyn^sdtruaetedto.ienmptSSevseviuehn. t.iilBatisioncosrtruedlayt.es with minimairestric xve uiseah
ENVIRONMENTAL DATA: Somplo typo *
ASBESTOS: Number Pibars > 5 Mu./Cucm. OTHER: SIUCA Mgs./M)
duration
;>
am I no. pfithnhly linn v*ry ihUiI iiulnnnnry AI
l.y, jiiolmlilv n
Imll on jiuil ly l lto oui ly ihisbI iif ptilMUXit: y aw|>liy aaiaii, 'I'liI u 1*1 ^*l *# I < l>
tuLon i.u/jo/75 indicates couio uiild luevacua iu' peripheral ixurouiu umi
more importantly some changes in the heart shadow size and lof it's cor.figuruti
Examinee should be advised of these changes and directed to donsuli with his personal physican. Overall pulmonary funo<i<fo appear^ to be/tmehanged.____ M D
BU77ALO IKDUS72AL .VJDICAL CSv72
ns tonawanda tnsr
bupfalo, n. v. 14207
Telephone 070-1214
- K2A3WG SVAU3A7!!0^ SU??i2l357
PREPLACEMENT
PERIODIC
BASELINE rY^l No]
EXAMINEE:.
S.i. Na P^503115i AGE
PREVIOUS
DATE:
employer ..G.e.QZ^aJ^SLiiic_
JOB ASSIGNMENTS
POE WHOM!
IS PERSONAL PROTECTIVE EQUIPMENT WORN [Yes [No
hftiMiil Occupalioeol Hiitoryi hi,
-
scaai^t:c.>]
Pertinent Medical History i.
/Ulwgin___ Head Injury-
tinging in EarsMisc.--------------
-Painful Can
-VertigoJbuw| Cart-
Military Service. Online.
. Duration-
APPLICANT'S EVALUATION OP HEAMNO STATUS
Normal
0
Nat Normal Q
Comtant 0 Variable 0
Onset
0
Progression 0
lot trouble hearing
la Croups 0
In Awditeria 0
In Naiiy Placet 0
At Distance 0
Close 0
Telephone0
Radio-TV
Women and Children 0
tecavse of Ringing in San 0
Ears Drains Ccr.ci
NOSO
Three?
Tuning Fork
*
L
Date:2/1Q/.7.7_________ ___Tim*:
A*iUsW4VJL.wW Jw4uVu-W-ee.iW.Ni Intmrval sine* last nois* *xposur*s
A O O ITfTIU
ostu proposed jrrriM______
tlfkt ler Hx
Uft ter
(0 ISO to
iOOM
p to 1000
\ <r 2000
S IP
__30|00 __ ..Vij
4000
bS
fo
*000 (000 AVIRACE T.S. in 4b
PS,
vs
f 1*'
__ 1__
AUDIOMETER AM. NAT'L STAND SPEC (ANSI-1949)
AIR BONE
LETT EAR EIGHT IAS
SLUE KID
X o!O
s
e MAIVN L AM0U1. M.D.
oactl A. CAFUTI, M.D
MAtOLO L CHAFF, MJ). ,-OMn'H. STIACHAN, MO.
Fresant Mai (Wbot 4o yoe dal
:WiTMtW uWWJiiuAtt
ikiA
755 TONAWANDA STBEiT BUFFALO, a Y. 14207 THEPHONS: S75.1514
PERIODIC HEALTH EXAMINATION REPORT
_________________________ OATI.2/10/2ZMHQYj?SSKgIXggBa Georgia gac
Euory day
Hrs./dgy
days/wk.
oonths/yr.
FmiMi wfmwii hm -- wku -- <mi4 tar haw long Silica -- toad foundry, ainiag, quarrying, caroaics Silicates -- tak, osbestas (typo) aining, milling, tabricatiaa, application, taatilot, other
tart
yocrs.
INQUIRY
YES
1. Cough 2. Chart poin 3. SOB at toil 4. SOB on often 5. Expectoration A. Sloop Bat h.i. 7. Pillows 0 -/T> 2 3
1. Los; wgt./appetito InerMting foligw**
10. Dysphagia 11. Change in bowel habit 12. Blood ioii
Cough
*
Vomit
Bloody ilool Block stool Urine Skin
13. Saokiag cigor/pipa/sig 't ____________________ # ph./doy for________ yoors
NO F-" A--
A"* U-
PHYS1CAI EXAMINATION___________AGE; &0_________ HEIGHT; S'l"_________ WEIGHT; 245 MUCOUS MEMBRANES {pigment, pallor, neoplasia)
CHEST; CONTOUR
"i
EXPANSION MOBILITY DIAPHRAGMS AUSCULTATION
. . - '
.. .
.
i". . : ,,
i\D
; ' - : r.
.''T
; J
HEART: Rhythm, rate, tones, murmurs, B.P.
ABDOMEN: Liver/Spleen
EXTREMITIES: Edema, dubbing, atrophies
NEUROLOGICAL
PCN
.JTANEOUS
Dermatitis l'i{|Uir,iil<ilioil Neoplasia
Examine**! Signature
' .-
Signature
DTR ADENOPATHIES
--............. .................... r-------------------------------------------
-
. M.D.
F.V.C = 'V7Ti
FEF 25%.75% IMPRESSION:
ELECTROCARDIOGRAM
Anoxia:
Q
P Pulmonale:
Right Heart Strain:
Abnormalities of rhythm:
Abnormalities of conduction:
Other:
r.t.v.1=`fyptl
F. E. V.3 =
iitere/sec. M. V. V.
IQ*() *
OBSTRUCTIVE
liters/minute RESTRICTIVE
NO DIAGNOSTIC ABNORMALITIES STT segment change*
BLOOD COUNT
NORMAL
ABNORMALITIES
BLOOD CHEMISTRIES
SMA 12/60: See Attached SERUM ENZYMES:________________________ SERUM ELECTROLYTES: No+ K+ Mg++ SERUM ALPHA I, ANTI TRYPSIN_________ SERUM ELECTROPHORESIS: See Attached
BLOOD LEAD:MICROGRAMS %
MISCELLANEOUS: ACHLORHYDRIA (DIAGNEX): OCCULT BLOOD:
URINALYSIS: ALBUMIN___ -- SUGAR
| | URINE LEAD
_ MICROGRAMS/LITER URINE SULPHATE RATIO
%
CHEST XRAYNORMAL
ABNORMAL
' UICC/CINCINNATI
Moderate fibrosis of both roots, sit. fibrosis of all lobes. Some increased radiability in both uppers, particularly the left. Nairy fibrosis is not spec ific. There is no evidence of pleural dysplasia. The heart shadow appears broadened in it*s transversed diameter. This film compared with previous study #9015-talcen IQ/3Q/75. indicates in essence no change.-----------------------------------------------------
OTHER
ENVIRONMENTAL DATA: Sampla typa
ASBESTOS: Number Fibers > 5 Mu./Cucm. OTHER: SILICA Mgs./M3
duration
RTamin.ee does have evidenoo of modpraye pulmonary :fi\i>rnsis or a
A. CilMMAUt. ||iii|"A|iuii| I Ml Vi* :'Il*:|. n.ihm; I < I i.l U 1 lit u*y U V I 11
; i I |ill I iiinniii ;
J'uuckioii defect. Chest x-ruy uui ventilation stuii\o ure unciimifcod over sLmiiiih
of 1975. Please advise. Attached audfGgram is satisfactory.
\ mi
\/
;I k i
B __M.D.
BUFFALO INDUSTRIAL W5DJCAL GN7Z2
7U TQNAWANBA STURT
SUPPAIQ, N. Y. 14307
Taiapkaaa 875-H14
EXAMINES:.
PMPiQYga
- K5AS2NG EVALUATION SU/PL5IU2X?
PREPLACEMENT
PERIODIC
BASELINE JY^T| No]
________________________________S.S. ^.095-01-9800 AG._6L
PREVIOUS
DATE:
Georgia Pacific
JOB ASSIGNMENT:.
FOR WHOMi
IS PERSONAL PROTECTIVE EQUIPMENT WORN Yes No
Partiaaat Oc*national HiMoryi.
KAL'iSNATICN
Partinant Madical Hillary:.
Ears Drums Cana!
Nos
R
L
Dwtiai..
APPLICANT'S (VALUATION OP HIAIING STATUS
Normal
O
Not Normal Q
CmiHhI O Varloblo O
OaMl
Prograuion
Mo* Irwbia kaoring
la Grovpi O
la Avditoria
la Nolly Plocat
At Diitanca
Oom Q.
Talaphona
Radio*TY Q
Womaa and Childran
lacouta of tinging ia Eon Q
Q
Throat Tuning rork
Ai rvrt
rr* a
at
2/10/77
Dale.-
Time:
______________ Interval since last noise exposure:
FIEQUENCY. HEITZ (Hi) & &
44 s ISO 500 1000 2000 <F $ f #
i i_________
J_________
. l '________
9 t
i
1
2Li
____v:/
ts
^7
EL
J9
xX A (
V-t ___l.
/
a
AJL.O.O. "" OSHA PtOPOSCD SYSTEM______
ubt Ear
(C
(O ! to 1Q
Uc..
Hs 3S0 soo 1000 2000
Loft Ear
sC-J
if :
tu :
ill
___1__
__ i__
Z
J
w
SI to;-
OK
QtZ'OMAim )Xn ttjmi H.dnim >
\ 1
Am
to a
a
a
*vr S>"6 *000 *000 AVERAGE
Irb T.S. in 4b
y<t
Sit
( (:
WU/rS/i/o/l//////A
/ \ m. ia
AUDIOMETER AM. NAT'L STAND SPEC (ANSI-1969)
AIR BONE
LEFT
jEAR
RIGHT
O oEAR
SLUE UD
yj A
Examinee's Signature: Examiner:
- ,*
.
. to'itv A. CAPUT1, MX
MASOLO L GtAJf, MX.
JOHN N. STIACHAN, MX.
We **%
7S5 TONAWANOA STUST SUffAlO, N. T. 14207 IBVHONSi >75-1 SI4
PERIODIC HEALTH EXAMINATION REPORT
NAME.
____________ _
____________ ;
PreMnt duties (Whot do you 4a1
----------S--DATI,--1/26/.71--employes.--georgia Pacific,
S^i?***! dvtfQ Tm ^T'
Every day
HnVdor
doy/wk.
montht/yr,
hraioi uMwni where -- whoa -- on4 for how long Silko -- Mn4 foundry, mining, quarrying, araoia Silicate. -- tek. oibe.to. (typo) erinlng, milling, fabricotion, application, taxtilM, other
Ion /)
yon.
INQUISY
YES
t. Cough 2. Chatt pain 3. SOS at ml 4. SOS on effort S. Expectoration 6. Sleep Sat h.$. 7. Pillow. 0 1 2 3
S. Lou wgt./appetite 9. Increa.ing fatigue 10. Dysphagia 11. Change in bowel habit 12. Stood leu
Coufh Vomit Bloody .tool Black .tool Urine Skin
13. SMkinfl cigar/pip*/cig*ts
_____________
# phi./doy tor________ year.
NO iX* is
r )/ /' (
u4-- if-
+--
u-
PHYSICAL EXAMINATION .
AGE. 60__________HEIGHT;_________________ WEIGHT;
MUCOUS MEMBRANES (pigment, pallor, neoplasia)
CHEST.
CONTOUR EXPANSION MOBILITY DIAPHRAGMS AUSCULTATION
HEART; Rhythm, rets, tones, murmurs, B.P.
ABDOMEN; Liver/Spleen
EXTREMITIES; Edema, dubbing, atrophies
NEUROLOGICAL
PCN
DTR
VNEOUS
Dermatitis Pigmentation Neoplasia
Examinee's Signature
Signature
ADENOPATHIES
(tight Heart Strain: Abnormalities of rhythm: Abnormalities of conduction: Other:
BLOOD COUNT
NORMAL
ABNORMALITIES
BLOOD CHEMISTRIES
SMA 12/60: See Attached SERUM ENZYMES: SERUM ELECTROLYTES: Na+ K+ Mg++ SERUM ALPHA I, ANTI TRYPSIN SERUM ELECTROPHORESIS: See Attached
BLOOD LEAD:MICROGRAMS %
MISCELLANEOUS: ACHLORHYDRIA {DIAGNEX): OCCULT BLOOD:
URINALYSIS: ALBUMIN___
SUGAR , -gll--URlfclf LEAD.
CHEST XRAY S wr NORMAL ??.
ABNORMAL
MICROGRAMS/UTER URINE SULPHATE RATIO UICC/CINONNAT1
%
OTHER
Moderate prominence of the root areas. Peripheral lung fields are generally not remarkable. Heart shadow normal in size, position and configuration. The bony cage is normal. The lateral projection does seem to indicate some increase in retrocardiac area radiolucency.
ENVIRONMENTAL DATA: Somple type
ASBESTOS: Number Fibers > 5 Mu./Cucm. OTHER: SILICA Mgs./M3
duration
nn*-
*. ciiMMMiV. FsMiiine rlnoq present In I lie lung funr.Mnn si u<1!eq eviiletu a ,.f ni r-
Wey kI-sU ilCL i.uiij Cmnpai cJ LO Lite slu>lica
JV/y, lb I .*> him luu.^^.|.
Chest x-ray is unchanged. Examinee denies, incidentally, any subjective
complaint.
Ti
He should be advised as to the presence of some airway obstruction.
U\ changed over the studies of 1975. Hia-^W
^------ r----------
............. *<* ti-vt'v I"*1
'
. f iiii':
SifivALO IW2U5T2IAL M595GA1 CZEZt
711 T0NAWAN9A SHOT
SUPPALO, N. Y. 14207
Talagltaaa *75-1314
KSA2S4G aVAlUATON SU??i2VSN7
PREPLACEMENT
PERIODIC
xggx
BASELINE Yes -No]
EXAMINES*
S.S. No.^fe,1236j2____________________P_R__E_V_I_O_U__S______AGE.--.0-
OATEi
employer_____ Georgia .Pacific
JOB ASSIGNMENT!
POR WHOM:
IS PERSONAL PROTECTIVE EQUIPMENT WORN 1 Yes I No |
MimM Occ.polieaal Hiitoqri.
EXA.V-XATIC.'VJ
PartiMai Medical Hiltiryi.
Allargioi____ Hnd Injury.
tinging ia fan. Mitc._________
Jeiahl fare.
_lnaing fare.
Military SorvicaDuliat----
. Daratiao-
APPLICANT'S fVAlUATlON OP HEARING STATUS
Normal
Q
Nat Normal p
Constant VoHobU Q
Ontal
Q
Progression Q
Nat trouble baaring
la CfMpi Q
a Aoditorio Q
la Noity Placet p
At Oitlanca p
Oot* Q
Telephone
tadio-TY Q
Womaa and Children Q
Because of fingiag ia fore Q
P
Threat Tuning ?ork
Date:1/26/?.?____________ Time:
audicvjttj: f5*p.A
A*r'p*`*..ti
- _____Interval since last noise exposure:
a A a ft imru
_
OSttA PROPOSED SYSTEM__
KJfM 1of Hs UA Ur
/o ISO to
to SCO sr j
To 1000
nr1 1000
r !i
o ;;i
/.s.Tj <r<> 4000 lf r> U < 4000
SOOO
r-3 ATVItfntAG4kI
AUDIOMETE2 AM. NAT`1 STAND SPEC (ANSI-1969)
AIR BONE
LEEAPRT SlUE X
REIGAHRT UD o c
examinee's Signatufi Examiner:__
v
tuCSf
r
. ft
POSITION T H IS EOOE NEAREST C A B IN E T
. :%. . M.J.
Jir*A. CAPUTJ, MJ> HAtOlO L OlAff, ALD. JOHN N. STtACHAN. MJ>.
NAME:_______________________ fmmt duties (What do ym do}
v
os *-> w .
V Mt
7SS TONAWANSA STBiCT BUALO, N. Y. 14307 TRBHONI. S7S-1S14
PBUODIC HEALTH EXAMINATION REPORT
flATi. 1/14/77
employes, Georgia Pacific
tnrf day____________________ Hnjdoy_______________daysArk.________________moaths/yr._______________ fori______________years.
hniwi uptnrti where -- kn -- end ter haw long Silica -- icuid laundry, owning, georrying, onaia Silicates -- tote, asbestos (typo) i mining, milling. fabrication, application, toatilas, otbor
INQUIBY
1. Cough 2. Chut, poin
3. SOS at rott 4. SOS on effort S. hpactoration
4. Sloop Sot ha.
7. Pillows 0 1 - 2 - 3 . . Lots wgt./appotito 9. Increasing fotiguo 10. Dysphagia
11. Change in bowel habit
12. Sioad lost
Coufh
Vomit
Bloody stool Block stool
Urino
Skin
13. Soaking cigar/pipe/cig'tt
___________ TV
# pkt./doy for
YES -
NO *7ue> /TUd TLr-
,
/ vu?
Tuc ... 7l*> v
yoort
PHYSICAL EXAMINATION___________AGE.________________HEIGHT._________________ WEIGHT: MUCOUS MEMBRANES (pigment, pallor, neoplasia]
CHEST.
CONTOUR EXPANSION MOBILITY DIAPHRAGMS AUSCULTATION
HEART. Rhythm, rata, tanas, murmurs, B.P.
ABDOMEN. Lhrer/5plean
EXTREMITIES. Edama, dubbing, atrophias
NEUROLOGICAL
Cw.ANEOUS
Darmatitis
Pigmentation Neoplasia
Examinee's Signature ,
PCN
. .
DTR ADENOPATHIES
Signature - ' u.
F.V.C
P Pulmonole: Right Heart Strain: Abnormalities of rhythm: Abnormalities of conduction: Other:
BLOOD COUNT
NORMAL
ABNORMALITIES
BLOOD CHEMISTRIES
SMA 12/40: See Attached SERUM ENZYMES:________________________ SERUM ELECTROLYTES: No+ K+ Mg++ SERUM ALPHA I, ANTI TRYPSIN_________ SERUM ELECTROPHORESIS: See Attached
BLOOD LEAD:MICROGRAMS %
MISCELLANEOUS: ACHLORHYDRIA (DIAGNEX): OCCULT BLOOD:
URINALYSIS: ALBUMIN___
SUGAR _ ^
URINE LEAD
MICROGRAMS/UTER URINE SULPHATE RATIO
V.
CHEST XRAY ^ WY NORMAL)
ABNORMAL
U1CC/CJNC1NNATI
Mild pTBmlnence of the right root, a few calcific densities noted in it. Parenchymal lung fields are not remarkable. There is no evidence of pleural dysplasia. Heart shadow normal in size, position and configura tion. The bony cage is normal. In essence, no change from previous film ---------------- #8893,. taken 10/21/75.--------------- ----------------------------------------------------------------------------------------
OTHER
ENVIRONMENTAL DATA: Sample type
ASBESTOS: Number fibers > 5 Mu./Cucm. OTHER: SILICA Mgs./M3
duration
Note absence of subjective complaint. Ventilation studies and
MISC. A SUMMARY: rhaet v.rav etnrfl oc 01*0 eat! sfar+nrw: F.vominoo nreceritc a mi 1 r
A!
.M.D.
BUFFALO K3US72ZAL JmSSZCAL C2MT3
7U TONAWAMDA STREET
BUFFALO, N. Y. 14207
TaWpheaa S75-1S14
HSAB1NG EVALUATION SU??ULV3!7
PREPLACEMENT
PERIODIC
BASELINE |Yes| No]
EXAMINEE:.
.S.S. No...
.AGE.
PREVIOUS
DATE.
EMiuftygp Georgia Pacific
JOB ASSIGNMENT:
FOR WHOM.
IS PERSONAL PROTECTIVE EQUIPMENT WORN Yet | No]
Partiaaat Occapatieael Hillary. .......... ..
- , --. .
KA.MSXA730N
ftriiMNt Medical Hillary..
Allorqit__ Hood lajvry-
Riaqinq ia Eon. Mite, i
-Paiafai Can.
.Vertlqo-Raaaiaq Eon.
Military SarvicaDuliat--____
. Daretiaa.
APPLICANT'S EVALUATION OF HEARING STATUS
Normal
0
Nat Nanael Q
Hat traabla heorinq
Ceaitant 0
VartaWa 0 Yat
Ontol
0
Fraqrattiofl- 0
la Oraapt 0
ia Auditeria 0
la Naity Flacat 0
At Dittance 0
Cioto 0
Tatopfceaa
tadiO'TV 0
Waaiaa aa4 Childrea 0
Sacaata af liaqiaq ia San 0
0
Ears Drums Car.ci
Noso
Throat
Tuning Fork
R
L
AUEQftfJaBSC
Dale:
. Time:
.Interval since last noise exposure:
FREQUENCY - HERTZ (Hs)
// //44
ns
iso
soo
1000
2000
LNtns:'i ...i j 1t
uSU a
l
1 i?--L___
'N
*--^ /l
s
f
* /
\
/ ()
U /_v *
\
\\
\ _y \*
AAAA IVCTfffl
OSHA FtOFOSCO SYSTEM.____
U|M tar tp
Hx Utt tar ISO [Z5Z
i
[fo
^P i 7-^3--
*o
1000 2000 MOO 4000
t io\
%n O
TZyVaiH*at^jz
l^lt CnvU Mam. '
\/LSll *i
\ Zik Q> A zm m.
* c 4000 .SD
000
/V"
2H
AVIIACI T.S. in a
AUDIOMETER AM. NAri STAND SPEC. (ANSI-1969)
AIR BONE
IEFT
IAK
SlUE
/\
o cSIGHT
EAt
IE9
,1
examinee's Signature
Examiner:---------
r,
PO SITIO N T H IS EOOC NEAREST CABINET
-. M.O. ROBERT A. CA7UTI. MM HAtOlo'* GIfft, MM.
JOHN N. jTRACHAN. MM.
DWu'MkW HlWWonink ImiWIWMfc Clit^lklk
711 TONAWANOA STRUT MfffAlO, N. Y. 14207
nUTHONIi S7S-15I4
PERIODIC HEALTH EXAMINATION REPORT
NAM*.________ . ;OaTI. 1/26/77IMWOYM.--Conyg-Ifl Pacific.
fMiMl dutiei (Whet 4o you Ml .
Eeary day
Hrs./day
dayr/wk,
menthi/yr.
TmiMi tipomni whan -- kw -- ud far haw leag Silica -- toad foundry, auniag, geonyieg. caraarics Silicata* -- talc, aibeito* (lypa) 1 aUalag, ailliag, fabrication, application, tactile:, athar
far,
yon.
1. Cough
INQUIRY
YES
/
2. Chart pain
3. SOS at ml 4. SOB on effort
S. Expectoration
A. Sleep Rat h.i.
7. r.llo> 0(\)-2-3-
S. Lett wgt^appelita
9. Increeiing fatigue
10. Dysphagia
11. Change in bowel habit
12. Blood lou
Coefh
Vomit
Heady ttaol
Slack stoal
Urine
Skin
'll)13. SaMking dnar/piaa^io
# pki./doy far 3-A. year,
NO
/ S'
1/
y
1/
s y y
PHYSICAL EXAMINATION
AGE: 38
MUCOUS MEMBRANES (pigment, pallor, neoplasia)
HEIGHT,
lN /? *10 /w* Z0/*
WEIGHT,
CHEST:
CONTOUR EXPANSION MOBILITY OIAPHRACMS AUSCULTATION
HEARTi Rhythm, rate, tones, murmurs, B.P.
ABDOMEN, Liver/Spleen
EXTREMITIES, Edoma, clubbing, atrophies
NEUROLOGICAL
e NEOUS
Dermatitis
Pigmentation Neoplasia
Examinee's Signature
PCN ' ^ V'' / ' .; .
. ' 1
^
Signature
DTR
ADENOPATHIES ...............
F.V.C. =
\
Right Heart Strain: Abnormalities of rhythm: Abnormalities of conduction: Othari
BLOOD COUNT
NORMAL
ABNORMALITIES
BLOOD CHEMISTRIES
SMA 12/60: Saa Attochad SERUM ENZYMES: SERUM ELECTROLYTES: No+ K+ Mg++ SERUM ALPHA I, ANTI TRYPSIN SERUM ELECTROPHORESIS: Saa Attochad
BLOOD LEAD:
MICROGRAMS %
MISCELLANEOUS:
ACHLORHYDRIA IDIAGNEX): OCCULT BLOOD:
URINALYSIS: ALBUMIN___
SUGAR.
.URINE LEAD.
-MICROGRAMS/LITER URINE SULPHATE RATIO
.%
CHEST XRAY^
(NORMA
ABNORMAL
UICC/GNCINNATl
Moderate prominence of both root areas, some general increase in bronchovascular markings over all lobes. Heart shadow and bony cage are normal, essentially unchanged from previous studies.
OTHER
ENVIRONMENTAL DATA: Sampla typa___________ duration
ASBESTOS: Number Fibers > 5 Mu./Cucm. OTHER: SJUCA M9I./M3
examinee has no subjective complaints. Ventilation study demonstrates
.M & r.iiMMAYV,'i'V mild n1inl*T*nr I'. 1 Vf> clmuy.ci. f'.lionl*. x-r#tv in itol run nrl- nll
AiIvin*'
i'.xcuuiuuo UwiL :A.uuiii cauUiInn unchanged. Such evidence oi- mild airway ob
struction which he has, apparently does not produce complaint! Audiogram
indicates mild hearing loss in the right ear.
.. M.D.
BUFFALO INDUSTRIAL ftiZDIGAL CEC3
7U TONAWANBA SHOT
BUFFALO, N. Y. 14307
Talophona S7S-1J14
PREPLACEMENT
HSAS1MG EVALUATION SU??L&7N?
PERIODIC
!S>
38 BASELINE rYeTT No]
EXAMINEE:
employes Georgia Pacific
No.i Q99-28-9.71Z... age-~3____ PREVIOUS OATEi
JOB ASSIGNMENT:.
FOR WHOMi
IS PERSONAL PROTECTIVE EQUIPMENT WORN |Yes|No|
Portiaoat Occapotionol hiiHryi -
EXA.VJNA7ICN
Ntliiml Modicol Hiitoryi.
Allargiat-- Haod Injury.
Binging in EonMix. .
-Palatal Eon.
-Vortigo Jtanaing I
Military Scrrico-
Duii
. Duration-
APPLICANT'S (VALUATION OP HEARING STATUS
Normal
Not Normal Hat trouble lowing
Vat No
In Awoitorio
Al OitMnca Q
Rodio-TV
Oontlonl Q VaHobia Q
Onto*
Prograttion Q
In Graapt
la Noity Placat
Ooto Q
Talapfcono
Woman and Children Q
Q
Socoata oi Kinging in Can Q
Ears Drums Canal
Noso
Throat
Tuning Fork
R
L
Date:
1/26/77
Tim*:
AUDJOaV^TTJC
______________ Interval sines last nois* oxpoiuror.
iwriu _ , , OSHA PROPOSED ITST Hakt Ear HS Uft hr
30
r*2S...
\5
ISO 500, .'*~4
1000 2000 t ft ii
l|l
./jSlT.j
2G
tC MOO' 000
Jkj TA.VSC. fe1*AG6ke
3 ft
t~
AUOIOMETER AM. NAT'l STAND SPEC (ANSM969)
AIR BONE
LIFT EAR
EIGHT EAR
SLUE RED
X o
EEMAIKS
Examinee's Signotur Examiner: