Health Monitoring Questionnaire | Green Keeper Medicals

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- Step 1 of 4

Company/Organisation Name *

Employee Name *

First

Last

Date of Birth *

Gender *

Weight *

Height *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone *

Email *

Employment Start Date *

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Employment in organophosphate pesticides risk work

Tick all relevant boxes

Type of organophosphate pesticide used *

New to organophosphate pesticides work
New worker but not new to organophosphate pesticides work
Current worker continuing in organophosphate pesticides work

Worked with organophosphate pesticides since: *

Type of organophosphate pesticide(s) used: *

When last used: *

Risk assessment completed: *

Pattern of exposure *

Frequent (daily; 5 or more days in a work week)
Regular (2-3 days in a work week)
Occasional (2-3 days in a work month)
Infrequent (1 day or less in a work month)
Seasonal (several days a week for a season)

Duration of exposure

Long – 6 or more hours in a day
Short – 1-5 hours in a day
Brief – less than 1 hour a day
Minimal

Minimal – describe: *

Work environment assessment

Organophosphate pesticide industry/use *

Pest control
Manufacture and packaging
Transport, storage or distribution
Agricultural industry
Aerial crop spraying
Horticultural industry
Veterinary work
Farming
Seasonal field work
Laboratory work
Other (specify):

Other (specify): *

Other chemicals the worker may be exposed to: *

Controls

Safety goggles/face shield *

Respirator use *

Respirator type *

Local exhaust ventilation *

Overalls/work clothing *

Laundering by employer *

Wash basins and showers (with hot and cold water) *

Other please specify

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Past employment history

Have you ever worked in any of the following jobs?

If you answer ‘yes’ to any of the questions, please advise if you experienced any symptoms such as cough or wheeze or asthma when working.

Pest control or fumigation *

text Pest control or fumigation *

Manufacture or packaging of OP products *

text Manufacture or packaging of OP products *

Transport, storage or distribution of OP products *

text Transport, storage or distribution of OP products *

Agriculture *

text Agriculture *

Horticulture *

text Horticulture *

Farming *

text Farming *

Aerial crop spraying *

text Aerial crop spraying *

Veterinary work *

text Veterinary work *

Seasonal field work *

text Seasonal field work *

Laboratory work *

text Laboratory work *

Other (please specify) *

Other (please specify) Comments *

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General Health Questionnaire

If you answer 'yes' to any of the questions, please provide more details.

1. Did you suffer any incapacity lasting two weeks or longer in the last two years? *

text 1. Did you suffer any incapacity lasting two weeks or longer in the last two years? *

2. Have you ever had any operations or accidents or been hospitalised for any reason? *

text 2. Have you ever had any operations or accidents or been hospitalised for any reason? *

3. Are you currently being treated by a doctor or other health professional for any illness or injury? *

text 3. Are you currently being treated by a doctor or other health professional for any illness or injury? *

4. Are you currently receiving any medical treatment or taking any medications? Please detail. *

text 4. Are you currently receiving any medical treatment or taking any medications? Please detail. *

5. Do you practice personal hygiene at work, for example nail biting, frequency of hand washing, eating or smoking, clean shaven, shower and change into clean clothes at end of shift *

text 5. Do you practice personal hygiene at work, for example nail biting, frequency of hand washing, eating or smoking, clean shaven, shower and change into clean clothes at end of shift *

Specific Health Questions

If you answer 'yes' to any of the questions, please provide more details.

Do you have or have you ever had:

1. Blurred vision or other vision problems *

text 1. Blurred vision or other vision problems *

2. Itchy eyes, runny or congested nose *

text 2. Itchy eyes, runny or congested nose *

3. Loss of hearing or ringing in the ears *

text 3. Loss of hearing or ringing in the ears *

4. Chest pains or irregular heartbeats *

text 4. Chest pains or irregular heartbeats *

5. High blood pressure or heart disease (including heart attack, heart surgery, murmurs, angina) *

text 5. High blood pressure or heart disease (including heart attack, heart surgery, murmurs, angina) *

6. Shortness of breath on exertion *

text 6. Shortness of breath on exertion *

7. Wheezing, bronchitis or asthma now or in the past *

text 7. Wheezing, bronchitis or asthma now or in the past *

8. Allergies, hay fever, or allergic bronchitis *

text 8 Allergies, hay fever, or allergic bronchitis *

9. Severe head or spinal injury resulting in hospitalisation *

text 9 Severe head or spinal injury resulting in hospitalisation *

10. Severe headaches or migraines *

text 10. Severe headaches or migraines *

11. Chronic fatigue or tiredness *

text 11. Chronic fatigue or tiredness *

12. Significant weight loss *

text 12. Significant weight loss *

13. Any neurological condition affecting nerves in your feet or hands, your coordination or balance *

text 13. Any neurological condition affecting nerves in your feet or hands, your coordination or balance *

14. Skin disorders or dermatitis *

text 14. Skin disorders or dermatitis *

15. Any previous symptoms associated with organophosphate pesticides *

text 15. Any previous symptoms associated with organophosphate pesticides *

16. Any other significant health conditions *

text 16. Any other significant health conditions *

Medications currently taken that may affect blood test results:

17. Oral contraceptive pill *

text 17. Oral contraceptive pill *

18. Lithium *

text 18. Lithium *

19. Prednisone/cortisone *

text 19. Prednisone/cortisone *

20. Propanolol *

text 20. Propanolol *

Declaration

Declaration *

I declare that I have answered the above correctly and completely, to the best of my knowledge

Please read the following and sign where indicated Statement authorisation - I give my consent for the results of my green keeper medical examination to be given to my employer. I understand that my employer is obliged to keep my results in a secure and confidential manner. I also give my consent for the release of information contained in the health surveillance assessment to my treating or family doctor.

Did you receive any assistance by another person to complete this form? *

If Yes: provide details *

Signed *

Clear Signature

Date *

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EMPLOYEES HEALTH

Health Monitoring Questionnaire | Green Keeper Medicals

Employment in organophosphate pesticides risk work

Work environment assessment

Controls

Past employment history

Have you ever worked in any of the following jobs?

General Health Questionnaire

Specific Health Questions

Declaration

EMPLOYEES HEALTH

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