Document zQzywmV1rgJb31XnVQDzOD5g6

V ft ( ''A V K i " - ' ** ( '* t>. **'*- *'" * *, ^ U:^ t^**, - t l;B'llt*. ,*', ';^V*.,,>1'. . / f . , ' s'-- . * * R E EX A M IN A T IO N - INTERVAL t/STO R T OCCUPATIONAL HISTORY . T itle @1J o b _____________ A g * ^ . So* _ _ Dot Any specie! hesords .strain s? . ^ MEDICAL HISTORY R tc o d of IIIm i h i , !n[tri*a, operations Loot seen by * Physician Work time lost because of lllnost f lf b Any: Loss or goin In weight. t ' T 0 _ Why . INnosi Less of oppetite MMWl Nowsec 9 vomiting M A. Chong* in bo*I oction Roctel blooding A ?6 Shortness of tveath r ^ * * * ^ < _ Chest pain O troiie eowA A f$ _____ Eos* STfetigue * Hemoptysis / ^ & Nervous i'iV SUMMARY Interval histvy.end jeesent physical esominatian . Recane<endetims & Disposition > *. Lim itations on' Employment fZ]o- i " ... V Sipw f W< 94065' R E -^ A M IN A T IO N - INTERVAL & ST O R Y fi t N im ^ 5 43- Data 3 . - .* * ~ ^ - ------- OCCUPATIONAL HISTORY T tfU IJ^ f f l r _________________________________ ;______:-------------------------------------------- J Any opacial hesords or strains? t J e - - ------- - MEDICAL HISTORY Record of i linos sas, injur las, opafotions Last soon by Physician i*S. "m e Work t mm lost b t c a u u of ilinass h> o i r Why Pci A \ Illn fJ Q u Any: La ar pain in NtwtM m oauting V o Rad! klaadiny kr o O tranic c m ^ i . V/ O sis N t3 <*Q *\ A TT Lass of appotito ^ c Cborvpa in bo-a I action M O Shortness of booth j 0 Otaot pain Easa of fatigue fi-l t ^ Narrows brackAo- ti W ? rL. i /, ^ '.iT rr . SUMMARY Interval history and prosaist physical examination Raceme on dot ions & D isposition Limitations an E n p U jaaot ` Signed M. 0 . -c-- t r--y ^ r-" 9406575  V -^-C tl- PERSONAL HISTORY O . 1 N as (^i^i i f c j^ k f c l _Ag . 3 2 . __Dot - S - LU - 5 " / 2 A ddress I L l i t " ,1 Slog] ( ) Widowed ( ) D ivorced ( ) Married Dapt M s f.h P ositlon Z t< - Prevlous P osltioa FAMILY HISTORY H as any nar r lativ had tubercu lo sis high blood pr**iur p-d h eart d is e a s e (fc#) s t r o k e s 'l l ) d ia b e te s V-0 c a n c e r (4 kldny d it e a i* fa) rnf a 9 Age of f a th e r_____ s o ther *T 8* If d e a d -c a u se J t c x l ^ How many brothers end s is te r s liv in g - A ges ' If dead-cause How many ch ild ren have yovu^ A aes 1 - -- I -- T .If d e e d -c a u se . -nervous troubles 1 A ge. Age __ 5 PAST HISTORY * Have you ev er had frequent sore throat tU) frequent colds fc? s in u s itis (b-i bronchitis p le u risy ?u) pneum onia h*5 tu b e rc u lo sis tkd s o la r ia f-d rheum atic fever frequent headache tL i bay fever asthma?*-) h iv es1 d eczem a'P-d c o n v u ls io n s')* ^ 6 If you were is m ilitary s e rv ic e -D a te s : from _________ t o _____________d is c h a rg e _________ O th er_____ 7 EMPLOYMENT HISTORY - P a s t 10 Y ears (New Em ployes Only) Employer & Position L ength of Service "- - N ature of Work 8 (New em ployes omit th is number) If you b eliev e that any c o n d itio n s of your work have any effect on your health, explain te examining physician 9 EATING - How many se rv in g s d a lly of - c e a t ^ w m llkvt?. eoos bread T . c h e e se ? * ., butter ^ < g re e n vegetablessi_starchy vegetables J t i saladsjtu.iruirv^aJples, cakes. pastry]lu.ie creamH_candy uz sw e e ts or & g a r *V-* * v 0 10 How much per day of - c o ffee A D e ta ils concerning item s 1 to 10 te a *>-s* tobocco `V o 9406576 ( 4 . * 's . . *A', *'* * ! . *' -** : * 'is - ' *" ' ' * 4'* . * r- X ' . . *.,*.. '""-t I*.*,**-r>^*7 . . . . * i -'c .- - \v .. . : ? ' .........?* * ::;# * `-a l t .: ^ :*" X E x ercise la addition to your work 12 R ecreatio n . p le a su re s, hebblM ' 13 Are you tifatog* to w nrrl -ftO emotional upsets - y * * BOOd> periods of alte rn a te gloom or ch eerfu ln ess -- 14 Have you bad any of the follow ing sym ptom s - explain when & how long - L o s s or gain In w eight lo s s of a p p etite Tib n a u s e a '7 4 * vomiting X*o chance in bowel action in d ia e e iin n ?Co oaln-oT craiBPS <V^g> trouble with urination, .sh o rtn ess of breath palpitation ifja chest pain cough blood Pitting > * ^ nervous breakdown V O w elling *%0 diarrhea TLo headaches w heezing hav fever -?*o bleeding frets rectum > * -a gas & belching T o Joint aches & pains ^ - ^ U u x w 15- Any a c c id e n ts , b ro k en `co n es or surQ ical o p e ra tio n s - When i L Where explain - ' Wh at 16 How s u c h tim e have you lo st from work in the post year b ecau se of illn e s s .t .Name of family physician 1 - - / A iJ L , 4. + (? ** 17. Do you use any m edicines - se d a tiv e s or lax ativ es l J w i ^ h m E xplain 16 How o ften do you c o n su lt your d e n tis t - J .When lo st 19 How often do you c o n su lt your o c u lis t When la s t. 20 F o r Women - Are y o u r'm e n se s re g u la r. .prolonged. Co yoa lo se time Iron w ork._ _ How many preg n an cies. Any com plications e x c e ss iv e . .painful* .Do you s till m enstruate. ,M iscarriages 21 Do you c o n sid e r y o u rse lf in good h e a lth D e ta ils eo o eerain g Item s 11 to 21 ___ ( J U G N A rU A C g '^ V *v Thm Imhrmmtle y ee beve yfven f t c e n ffd e e tfe f end th is r e ta rd f t le be re ta in e d fe *be M edicei D ept. n r r 9406577