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Asbestos Periodic Medical Questionnaire

Employees health related information is confidential. The medical questionnaire is automatically sent electronically to the reviewing physician.

Please answer all questions.



BYU ID: (9 Digit BYU ID)
First Name:   Last Name:
DOB: / /   Age:      Sex: M F
Height: ft in   Weight: lbs
Marital Status
Phone: (No Dashes)   Job Title:
Email:
Department:
Supervisor:

____________________________________________________________________________________________


In the past year, did you work full time (30 hours per week or more) for 6 months or more?
In the past year, did you work in a dusty job?
          Was dust exposure:
In the past year were you exposed to gas or chemical fumes in your work?
          Was exposure:
In the past year, what was your:
          Job/Occupation?    
          Postion/Job Title?  

____________________________________________________________________________________________


Do you consider yourself to be in good health?
          If NO, state reason:
         
In the past have you ever developed:

          Epilepsy?           Rheumatic fever?
Kidney disease? Bladder disease?
Diabetes? Jaundice?
Cancer?

____________________________________________________________________________________________


If you get a cold, does it "usually" go to your chest? (more than 1/2 the time)
In the past year, have you had any chest illnesses that have kept you off work, indoors at home, or in bed?
Did you produce phlegm with any of these illnesses?
In the past year, how many such illnesses with (increased) phlegm did you have which lassted a week or more?

____________________________________________________________________________________________


In the past have you had:

          Asthma?           Bronchitis?
Hay Fever? Other Allergies?
Pneumonia? Tuberculosis?
Chest Surgery? Other Lung Problems?
Heart Disease?
Futher Comment on Positive Answers:
Do you have:

          Frequent colds?           Chronic cough?
Shortness of breath
when walking or climbing
one flight of stairs?
Do you:

          Wheeze?
Cough up phlegm?
Smoke Cigarettes?       ---->   Packs per day?      How many years?:  


Other Comments or Concerns:



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, Student Health Center, BYU, Provo, UT 84602 - (801)422-5156 - Address/Directions. Copyright 2012. All Rights Reserved