Dd Form 2493-1 - Asbestos Exposure Part I - Initial Medical Questionnaire
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1
2ASBESTOS EXPOSURE
PART I - INITIAL MEDICAL QUESTIONNAIRE
IDENTIFICATION
1. NAME
2. SOCIAL SECURITY NO.
3. CLOCK NO.
4. PRESENT OCCUPATION
(Last, First, Middle Initial)
(1 - 9)
(10 - 15)
5. NAME OF PLANT
6. STREET ADDRESS OF PLANT
7. PLANT CITY, STATE AND ZIP CODE
8. TELEPHONE NO.
9. NAME OF INTERVIEWER
10. DATE OF INTERVIEW
11. DATE OF BIRTH
12. PLACE OF BIRTH
(Include area code)
(16 - 21) (YYYYMMDD)
(22 - 29) (YYYYMMDD)
16. HIGHEST GRADE
13. SEX
14. MARITAL STATUS
15. RACE (X one)
(X one)
(X one)
COMPLETED IN
a. MALE
a. SINGLE
b. MARRIED
a. WHITE
b. BLACK
c. ASIAN
SCHOOL
b. FEMALE
c. WIDOWED
d. DIVORCED/SEPARATED
d. HISPANIC
e. INDIAN
f. OTHER
MEDICAL DATA
17. OCCUPATIONAL HISTORY
Yes
No
N/A
Yes
No
N/A
21. DID YOU HAVE ANY LUNG TROUBLE BEFORE THE AGE
OF 16?
a. HAVE YOU EVER WORKED FULL TIME (30 hours per week or more)
FOR SIX MONTHS OR MORE?
22. HAVE YOU EVER HAD ANY OF THE FOLLOWING?
b. IF YES, HAVE YOU EVER WORKED FOR A YEAR OR MORE IN ANY
DUSTY JOB? *If Yes, complete (1) - (3).
a. ATTACKS OF BRONCHITIS * If yes, complete (1) and (2).
(2) Total
(1) Specify Job/Industry
(3) Dust Exposure (X one)
(1) Age at first attack
(2) Was it confirmed by a doctor?
years
worked
b. ATTACKS OF PNEUMONIA (Include bronchopneumonia)
MILD
*If yes, complete (1) and (2)
MODERATE
(1) Age at first attack
(2) Was it confirmed by a doctor?
SEVERE
c. HAVE YOU EVER BEEN EXPOSED TO GAS OR CHEMICAL
c. HAY FEVER * If yes, complete (1) and (2).
FUMES IN YOUR WORK? *If Yes, complete (1) - (3).
(1) Age at first attack
(2) Was it confirmed by a doctor?
(2) Total
(1) Specify Job/ Industry
(3) Exposure (X one)
years
23. HAVE YOU EVER HAD CHRONIC BRONCHITIS?
worked
MILD
a. IF YES, DO YOU STILL HAVE IT?
MODERATE
b. WAS IT CONFIRMED BY A DOCTOR?
SEVERE
d. WHAT HAS BEEN YOUR USUAL OCCUPATION - THE ONE YOU HAVE WORKED AT
c. AT WHAT AGE DID IT START? (List age)
THE LONGEST?
24. HAVE YOU EVER HAD EMPHYSEMA?
(2) Number of years employed in this
(1) Job/Occupation
occupation
a. IF YES, DO YOU STILL HAVE IT?
b. WAS IT CONFIRMED BY A DOCTOR?
(3) Position/Job Title
(4) Business, Field or Industry
c. AT WHAT AGE DID IT START? (List age)
25. HAVE YOU EVER HAD ASTHMA?
e. HAVE YOU EVER WORKED (X Yes or No
Years Worked
and specify years worked, e.g. 1960 - 1969.)
a. IF YES, DO YOU STILL HAVE IT?
(1) In a mine
b. WAS IT CONFIRMED BY A DOCTOR?
(2) In a quarry
c. AT WHAT AGE DID IT START? (List age)
(3) In a foundry
d. IF YOU NO LONGER HAVE IT, AT WHAT AGE DID IT STOP? (List age)
(4) In a pottery
26. HAVE YOU EVER HAD:
(5) In a cotton, flax or hemp mill
a. ANY OTHER CHEST ILLNESSES *If yes, please specify.
(6) With asbestos
18. MEDICAL HISTORY
a. DO YOU CONSIDER YOURSELF TO BE IN GOOD HEALTH? *If No,
b. ANY CHEST OPERATIONS *If yes, please specify.
state reason.
b. HAVE YOU ANY DEFECT OF VISION? *If Yes, state nature of
c. ANY CHEST INJURIES *If yes, please specify.
defect.
c. HAVE YOU ANY HEARING DEFECT? *If Yes, state nature of
27. HEART TROUBLE
defect.
a. HAS A DOCTOR EVER TOLD YOU THAT YOU HAD HEART TROUBLE?
d. ARE YOU SUFFERING FROM OR HAVE YOU EVER SUFFERED FROM
b. IF YES, HAVE YOU EVER HAD TREATMENT FOR HEART TROUBLE IN
(1) Epilepsy (Or fits, seizures or convulsions)
THE PAST TEN YEARS?
(2) Rheumatic Fever
28. HIGH BLOOD PRESSURE
(3) Kidney Disease
a. HAS A DOCTOR EVER TOLD YOU THAT YOU HAD HIGH BLOOD
(4) Bladder Disease
PRESSURE (Hypertension)?
(5) Diabetes
b. IF YES, HAVE YOU EVER HAD TREATMENT FOR HIGH BLOOD
PRESSURE IN THE PAST TEN YEARS?
(6) Jaundice
*
19. IF YOU GET A COLD, DOES IT USUALLY GO TO YOUR
29. WHEN DID YOU LAST HAVE YOUR CHEST X-RAYED?
(Year)
CHEST?
(Usually means more than 1/2 of the time)*Don't get colds
20. CHEST ILLNESSES
30. CHEST X-RAY
a. DURING THE PAST THREE YEARS, HAVE YOU HAD ANY
CHEST
a. WHERE DID YOU LAST HAVE YOUR CHEST X-RAYED? (If known)
ILLNESSES THAT HAVE KEPT YOU OFF WORK, INDOORS AT HOME,
OR IN BED?
b. IF YES, DID YOU PRODUCE PHLEGM WITH ANY OF THESE
b WHAT WAS THE OUTCOME?
ILLNESSES?
c. IN THE LAST THREE YEARS, HOW MANY SUCH ILLNESSES WITH INCREASED PHLEGM
DID YOU HAVE WHICH LASTED A WEEK OR MORE? (List number)
DD FORM 2493-1, JAN 2000
PREVIOUS EDITION MAY BE USED.
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