Appendix D

Regulations (Standards - 29 CFR)

Medical questionnaires; Mandatory - 1910.1001 App D
Regulations (Standards - 29 CFR) - Table of Contents

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Part Number:
Part Title:
Subpart:
Subpart Title:
Standard Number:
Title:

1910
Occupational Safety and Health Standards
Z
Toxic and Hazardous Substances
1910.1001 App D
Medical questionnaires; Mandatory

This mandatory appendix contains the medical questionnaires that must be administered to
all employees who are exposed to asbestos above permissible exposure limit, and who will
therefore be included in their employer's medical surveillance program. Part 1 of the
appendix contains the Initial Medical Questionnaire, which must be obtained for all new
hires who will be covered by the medical surveillance requirements. Part 2 includes the
abbreviated Periodical Medical Questionnaire, which must be administered to all employees
who are provided periodic medical examinations under the medical surveillance provisions
of the standard.
Part 1
INITIAL MEDICAL QUESTIONNAIRE
1.

NAME ________________________________________________________________

2.

SOCIAL SECURITY NUMBER # ____________________________________________

3.

CLOCK NUMBER ________________________________________________________

4.

PRESENT OCCUPATION __________________________________________________

5.

PLANT _______________________________________________________________

6.

ADDRESS _____________________________________________________________

7.

_____________________________________________________________________
(Zip Code)

8.

TELEPHONE NUMBER ____________________________________________________

9.

INTERVIEWER _________________________________________________________

10. DATE ________________________________________________________________
11. Date of Birth _______________________________________________________
Month
Day
Year
12. Place of Birth ______________________________________________________
13. Sex

1. Male
2. Female

___
___

14. What is your marital status?

1. Single ___
2. Married ___
3. Widowed ___

15. Race

16.

1. White ___

4. Separated/
Divorced ___

4. Hispanic ___

2. Black ___

5. Indian

___

3. Asian ___

6. Other

___

What is the highest grade completed in school? _____________________
(For example 12 years is completion of high school)

OCCUPATIONAL HISTORY
17A.

Have you ever worked full time (30 hours
per week or more) for 6 months or more?

1. Yes ___

2. No ___

IF YES TO 17A:
B.

Have you ever worked for a year or more in
any dusty job?

1. Yes ___ 2. No ___
3. Does Not Apply ___

Specify job/industry _______________ Total Years Worked __________
Was dust exposure: 1. Mild
C.

2. Moderate ____

3. Severe ____

Have you ever been exposed to gas or
1. Yes ___ 2. No ___
chemical fumes in your work?
Specify job/industry ______________________ Total Years Worked ___
Was exposure :

D.

____

1. Mild

____

2. Moderate ____

3. Severe ____

What has been your usual occupation or job -- the one you have
worked at the longest?
1. Job occupation ________________________________________________
2. Number of years employed in this occupation ___________________
3. Position/job title ____________________________________________

4. Business, field or industry ___________________________________
(Record on lines the years in which you have worked in any of these
industries, e.g. 1960-1969)
Have you ever worked:

YES

NO

E.

In a mine? .........................

_____

_____

F.

In a quarry? .......................

_____

_____

G.

In a foundry? ......................

_____

_____

H.

In a pottery? ......................

_____

_____

I.

In a cotton, flax or hemp mill? ....

_____

_____

J.

With asbestos? .....................

_____

_____

YES

NO

_____

_____

18.

PAST MEDICAL HISTORY

A. Do you consider yourself to be in good health?

If "NO" state reason __________________________________________
B. Have you any defect of vision? ...............

_____

_____

If "YES" state nature of defect _______________________________
C. Have you any hearing defect? .................

_____

_____

If "YES" state nature of defect ______________________________
D. Are you suffering from or have you ever suffered from:
YES
a. Epilepsy (or fits, seizures, convulsions)? _____

19.

NO
_____

b.

Rheumatic fever?

_____

_____

c.

Kidney disease?

_____

_____

d.

Bladder disease?

_____

_____

e.

Diabetes?

_____

_____

f.

Jaundice?

_____

_____

CHEST COLDS AND CHEST ILLNESSES

19A. If you get a cold, does it "usually" go to your
chest? (Usually means more than 1/2 the time)
1. Yes ___ 2. No ___ 3. Don't get colds ___
20A. During the past 3 years, have you had any chest illnesses
that have kept you off work, indoors at home, or in bed?
1. Yes ___ 2. No ___
IF YES TO 20A:
B. Did you produce phlegm with any of these chest illnesses?
1. Yes ___ 2. No ___ 3. Does Not Apply ___
C. In the last 3 years, how many such illnesses with (increased)
phlegm did you have which lasted a week or more?
Number of illnesses ___
No such illnesses
___
21.

Did you have any lung trouble before the age of 16?
1. Yes ___ 2. No ___

22.

Have you ever had any of the following?

1A.

Attacks of bronchitis?

IF YES TO 1A:
B. Was it confirmed by a doctor?

C. At what age was your first attack?

2A. Pneumonia (include bronchopneumonia)?
IF YES TO 2A:
B. Was it confirmed by a doctor?

C. At what age did you first have it?

3A. Hay Fever?
IF YES TO 3A:
B. Was it confirmed by a doctor?

C. At what age did it start?

23A. Have you ever had chronic bronchitis?
IF YES TO 23A:
B. Do you still have it?

C.

Was it confirmed by a doctor?

D. At what age did it start?

24A. Have you ever had emphysema?
IF YES TO 24A:
B. Do you still have it?

C. Was it confirmed by a doctor?

D. At what age did it start?

25A. Have you ever had asthma?
IF YES TO 25A:

1. Yes ___

2. No ___

1. Yes ___ 2. No ___
3. Does Not Apply ___
Age in Years
___
Does Not Apply ___
1. Yes ___

2. No ___

1. Yes ___ 2. No ___
3. Does Not Apply ___
Age in Years
___
Does Not Apply ___
1. Yes ___

2. No ___

1. Yes ___ 2. No ___
3. Does Not Apply ___
Age in Years
___
Does Not Apply ___

1. Yes ___

2. No ___

1. Yes ___ 2. No ___
3. Does Not Apply ___
1. Yes ___ 2. No ___
3. Does Not Apply ___
Age in Years
___
Does Not Apply ___
1. Yes ___

2. No ___

1. Yes ___ 2. No ___
3. Does Not Apply ___
1. Yes ___ 2. No ___
3. Does Not Apply ___
Age in Years
___
Does Not Apply ___
1. Yes ___

2. No ___

B. Do you still have it?

1. Yes ___ 2. No ___
3. Does Not Apply ___

C. Was it confirmed by a doctor?

1. Yes ___

2. No ___

3. Does Not Apply ___
D. At what age did it start?

Age in Years
___
Does Not Apply ___

E. If you no longer have it, at what age did it stop?
Age stopped
___
Does Not Apply ___
26.

Have you ever had:

A. Any other chest illness?

1. Yes ___

2. No ___

If yes, please specify ___________________________________________
B. Any chest operations?

1. Yes ___

2. No ___

If yes, please specify ___________________________________________
C. Any chest injuries?

1. Yes ___

2. No ___

If yes, please specify ___________________________________________
27A. Has a doctor ever told you that you had heart trouble?
1. Yes ___

2. No ___

IF YES TO 27A:
B. Have you ever had treatment for heart trouble in the past 10 years?
1. Yes ___ 2. No ___
3. Does Not Apply ___
28A. Has a doctor told you that you had high blood pressure?
1. Yes ___

2. No ___

IF YES TO 28A:
B. Have you had any treatment for high blood pressure (hypertension)
in the past 10 years?
1. Yes ___ 2. No ___
3. Does Not Apply ___
29.

30.

When did you last have your chest X-rayed?
(Year) ___ ___ ___ ___
Where did you last have your chest X-rayed (if known)?
_____________________________________________________________________
What was the outcome? _______________________________________________

FAMILY HISTORY
31.

Were either of your natural parents ever told by a doctor that they
had a chronic lung condition such as:

1. Yes

A. Chronic Bronchitis?

FATHER
2. No 3. Don't
know

1. Yes

MOTHER
2. No 3. Don't
know

___

___

___

___

___

___

B. Emphysema?

___

___

___

___

___

___

C. Asthma?

___

___

___

___

___

___

D. Lung cancer?

___

___

___

___

___

___

___

___

___

___

___

F. Is parent currently alive?
___
___

___

___

___

___

E. Other chest conditions?
___

G. Please Specify

___ Age if Living
___ Age at Death
___ Don't Know

H. Please specify cause of death
____________________________________

___ Age if Living
___ Age at Death
___ Don't Know

__________________________

COUGH
32A. Do you usually have a cough? (Count a cough with first smoke or on
first going out of doors. Exclude clearing of throat.)
(If no, skip to question 32C.)
1. Yes ___ 2. No ___
B. Do you usually cough as much as 4 to 6 times a day 4 or more days
out of the week?
1. Yes ___ 2. No ___
C. Do you usually cough at all on getting up or first thing in the
morning?
1. Yes ___ 2. No ___
D. Do you usually cough at all during the rest of the day or at night?
1. Yes ___ 2. No ___
IF YES TO ANY OF ABOVE (32A, B, C, OR D,), ANSWER THE FOLLOWING.
TO ALL, CHECK "DOES NOT APPLY" AND SKIP TO NEXT PAGE

IF NO

E. Do you usually cough like this on most days for 3 consecutive
months or more during the year?
1. Yes ___ 2. No ___
3. Does not apply ___
F. For how many years have you had the cough?

Number of years ___
Does not apply ___

33A. Do you usually bring up phlegm from your chest?
(Count phlegm with the first smoke or on first going out of doors.
Exclude phlegm from the nose. Count swallowed phlegm.) (If no,
skip to 33C)
1. Yes ___ 2. No ___
B. Do you usually bring up phlegm like this as much as twice a day 4
or more days out of the week?

1. Yes ___

2. No ___

C. Do you usually bring up phlegm at all on getting up or first thing
in the morning?
1. Yes ___ 2. No ___
D. Do you usually bring up phlegm at all on during the rest of the day
or at night?
1. Yes ___ 2. No ___
IF YES TO ANY OF THE ABOVE (33A, B, C, OR D), ANSWER THE FOLLOWING:
IF NO TO ALL, CHECK "DOES NOT APPLY" AND SKIP TO 34A
E. Do you bring up phlegm like this on most days for 3 consecutive
months or more during the year?
1. Yes ___ 2. No ___
3. Does not apply ___
F. For how many years have you had trouble with phlegm?
Number of years ___
Does not apply ___
EPISODES OF COUGH AND PHLEGM
34A. Have you had periods or episodes of (increased*) cough and phlegm
lasting for 3 weeks or more each year?
*(For persons who usually have cough and/or phlegm)
1. Yes ___ 2. No ___
IF YES TO 34A
B. For how long have you had at least 1 such episode per year?
Number of years ___
Does not apply ___
WHEEZING
35A. Does your chest ever sound wheezy or whistling
1. When you have a cold?
1. Yes ___

2. No ___

2. Occasionally apart from colds?

1. Yes ___

2. No ___

3. Most days or nights?

1. Yes ___

2. No ___

IF YES TO 1, 2, or 3 in 35A
B. For how many years has this been present?
Number of years ___
Does not apply ___
36A. Have you ever had an attack of wheezing that has made you feel short
of breath?
1. Yes ___ 2. No ___
IF YES TO 36A
B. How old were you when you had your first such attack?
Age in years
___

Does not apply ___
C. Have you had 2 or more such episodes?
1. Yes ___ 2. No ___
3. Does not apply ___
D. Have you ever required medicine or treatment for the(se) attack(s)?
1. Yes ___ 2. No ___
3. Does not apply ___
BREATHLESSNESS
37.

If disabled from walking by any condition other than heart or lung
disease, please describe and proceed to question 39A.
Nature of condition(s) ______________________________________________
_____________________________________________________________________

38A. Are you troubled by shortness of breath when hurrying on the level
or walking up a slight hill?
1. Yes ___ 2. No ___
IF YES TO 38A
B. Do you have to walk slower than people of your age on the level
because of breathlessness?
1. Yes ___ 2. No ___
3. Does not apply ___
C. Do you ever have to stop for breath when walking at your own pace
on the level?
1. Yes ___ 2. No ___
3. Does not apply ___
D. Do you ever have to stop for breath after walking about 100 yards
(or after a few minutes) on the level?
1. Yes ___ 2. No ___
3. Does not apply ___
E. Are you too breathless to leave the house or breathless on dressing
or climbing one flight of stairs?
1. Yes ___ 2. No ___
3. Does not apply ___
TOBACCO SMOKING
39A. Have you ever smoked cigarettes? (No means less than 20 packs of
cigarettes or 12 oz. of tobacco in a lifetime or less than 1
cigarette a day for 1 year.)
1. Yes ___ 2. No ___
IF YES TO 39A
B. Do you now smoke cigarettes (as of one month ago)
1. Yes ___ 2. No ___
3. Does not apply ___

C. How old were you when you first started regular cigarette smoking?
Age in years
___
Does not apply ___
D. If you have stopped smoking cigarettes completely, how old were you
when you stopped?
Age stopped
___
Check if still smoking ___
Does not apply
___
E. How many cigarettes do you smoke per day now?
Cigarettes per day
Does not apply

___
___

F. On the average of the entire time you smoked, how many cigarettes did
you smoke per day?
Cigarettes per day
___
Does not apply
___
G. Do or did you inhale the cigarette smoke?
1.
2.
3.
4.
5.

Does not apply
Not at all
Slightly
Moderately
Deeply

40A. Have you ever smoked a pipe regularly?
(Yes means more than 12 oz. of tobacco in a lifetime.)
1. Yes ___

___
___
___
___
___

2. No ___

IF YES TO 40A:
FOR PERSONS WHO HAVE EVER SMOKED A PIPE
B. 1. How old were you when you started to smoke a pipe regularly?
Age ___
2. If you have stopped smoking a pipe completely, how old were you
when you stopped?
Age stopped
___
Check if still smoking pipe ___
Does not apply
___
C. On the average over the entire time you smoked a pipe, how much pipe
tobacco did you smoke per week?
___ oz. per week
(a standard pouch of tobacco contains 1 1/2 oz.)
___ Does not apply
D. How much pipe tobacco are you smoking now?
oz. per week
Not currently smoking a pipe

___
___

E. Do you or did you inhale the pipe smoke?
1.
2.
3.
4.

Never smoked
Not at all
Slightly
Moderately

___
___
___
___

5. Deeply

___

41A. Have you ever smoked cigars regularly?
1. Yes ___

2. No ___

(Yes means more than 1 cigar a week for a year)
IF YES TO 41A
FOR PERSONS WHO HAVE EVER SMOKED A CIGARS
B. 1. How old were you when you started
smoking cigars regularly?

Age ___

2. If you have stopped smoking cigars
completely, how old were you when
you stopped.

Age stopped
Check if still
smoking cigars
Does not apply

___

C. On the average over the entire time you
smoked cigars, how many cigars did you
smoke per week?

Cigars per week
Does not apply

___
___

D. How many cigars are you smoking per week
now?

Cigars per week
Check if not
smoking cigars
currently

___

Never smoked
Not at all
Slightly
Moderately
Deeply

___
___
___
___
___

E. Do or did you inhale the cigar smoke?

Signature ____________________________

1.
2.
3.
4.
5.

___
___

___

Date _____________________

Part 2
PERIODIC MEDICAL QUESTIONNAIRE
1.

NAME _______________________________________________________________

2.

SOCIAL SECURITY #

3.

CLOCK NUMBER

4.

PRESENT OCCUPATION __________________________________________________

5.

PLANT ______________________________________________________________

6.

ADDRESS ____________________________________________________________

7.

____________________________________________________________________
(Zip Code)

8.

TELEPHONE NUMBER ___________________________________________________

9.

INTERVIEWER

___

___

___

___

___

___

___

___

___

___

___

___

___

___

___

___

_______________________________________________________

10.

DATE ___________________________

11.

What is your marital status?

12.

OCCUPATIONAL HISTORY

___

___

___

1. Single ___
2. Married ___
3. Widowed ___

12A. In the past year, did you work
full time (30 hours per week
or more) for 6 months or more?

1. Yes ___

___

___

___

4. Separated/.
Divorced ___

2. No ___

IF YES TO 12A:
12B. In the past year, did you work
in a dusty job?
12C. Was dust exposure:

1. Mild ___

12D. In the past year, were you
exposed to gas or chemical
fumes in your work?
12E. Was exposure:
12F. In the past year,
what was your:

13.

1. Yes ___
2. No ___
3. Does not Apply ___
2. Moderate ___

1. Yes ___

1. Mild ___

3. Severe ___

2. No ___

2. Moderate ___

3. Severe ___

1. Job/occupation? _________________________
2. Position/job title? _____________________

RECENT MEDICAL HISTORY

13A. Do you consider yourself to
be in good health?

Yes

___

No ___

If NO, state reason ______________________________________________
13B. In the past year, have you
developed:
Epilepsy?
Rheumatic fever?
Kidney disease?
Bladder disease?
Diabetes?
Jaundice?
Cancer?
14.

Yes
___
___
___
___
___
___
___

No
___
___
___
___
___
___
___

CHEST COLDS AND CHEST ILLNESSES

14A. If you get a cold, does it "usually" go to your chest?
(usually means more than 1/2 the time)
1. Yes ___
2. No ___
3. Don't get colds ___
15A. During the past year, have you had
any chest illnesses that have kept you
off work, indoors at home, or in bed?

1. Yes ___
2. No ___
3. Does Not Apply ___

IF YES TO 15A:
15B. Did you produce phlegm with any
of these chest illnesses?

1. Yes ___
2. No ___
3. Does Not Apply ___

15C. In the past year, how many such
illnesses with (increased) phlegm
did you have which lasted a week
or more?

Number of illnesses ___
No such illnesses
___

16.

RESPIRATORY SYSTEM
In the past year have you had:
Yes or No
Asthma

_____

Bronchitis

_____

Hay Fever

_____

Other Allergies

_____

Yes or No
Pneumonia

_____

Tuberculosis

_____

Chest Surgery

_____

Other Lung Problems

_____

Heart Disease

_____

Further Comment on Positive
Answers

Further Comment on Positive
Answers

Do you have:
Yes or No

Frequent colds

_____

Chronic cough

_____

Shortness of breath
when walking or
climbing one flight
or stairs

_____

Do you:
Wheeze

_____

Cough up phlegm

_____

Further Comment on Positive
Answers

Smoke cigarettes

Date __________________

_____

Packs per day ____

How many years ___

Signature ____________________________________

[57 FR 24330, June 8, 1992; 59 FR 40964, Aug. 10, 1994]