Health Monitoring Questionnaire | Spirometry

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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 *

Company/Organisation Name *

Employment Start Date *

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General Health Questionnaire

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

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

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

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

Comments - Have you ever had any operations or accidents or been hospitalised for any reason? *

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

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

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

Comments - Are you currently receiving any medical treatment or taking any medications Please detail. *

Do you currently smoke? *

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:

Shortness of breath on exertion *

Comments - Shortness of breath on exertion *

Wheezing, bronchitis or asthma now or in the past *

Comments - Wheezing, bronchitis or asthma now or in the past *

Any other lung or respiratory conditions (emphysema, pneumonia or sinusitis) *

Comments - Any other lung or respiratory conditions (emphysema, pneumonia or sinusitis) *

Allergies, hay fever, or allergic bronchitis *

Comments - Allergies, hay fever, or allergic bronchitis *

Does anyone in your immediate family (blood relatives only) have asthma, hay fever or eczema *

Comments - Does anyone in your immediate family (blood relatives only) have asthma, hay fever or eczema *

Significant weight loss *

Comments - Significant weight loss *

Any form of cancer *

Comments - Any form of cancer *

Any other significant health conditions *

Comments - Any other significant health conditions *

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Respiratory questionnaire

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

Cough and Phlegm

1. Do you usually cough first thing in the morning? *

Yes 1 Do you usually cough first thing in the morning *

2. Do you usually cough during the day or at night? *

Yes 2 Do you usually cough during the day or at night? *

3. Do you cough like this on most days for as much as three months of the year? *

Yes 3 Do you cough like this on most days for as much as three months of the year *

4. Do you usually bring up phlegm from your chest first thing in the morning? *

Yes 4 Do you usually bring up phlegm from your chest first thing in the morning *

5. Do you usually bring up phlegm from your chest at any other rime of the day or night? *

Yes 5 Do you usually bring up phlegm from your chest at any other rime of the day or night *

6. Do you bring up phlegm like this on most days for as much as three months each year? *

Yes 6 Do you bring up phlegm like this on most days for as much as three months each year *

7. In the past three years have you had a period of increased cough and phlegm lasting for three weeks or more? *

Yes 7 In the past three years have you had a period of increased cough and phlegm lasting for three weeks or more *

8. If Yes, have you had more than one such period? *

Yes 8 If Yes, have you had more than one such period *

Breathlessness

9. Do you get short of breath when hurrying on level ground or walking up a slight hill? *

Yes 9 Do you get short of breath when hurrying on level ground or walking up a slight hill *

10. Do you get short of breath walking with other people of your own age on level ground? *

Yes 10 Do you get short of breath walking with other people of your own age on level ground *

11. Do you have to stop for breath when walking at your own pace on level ground? *

Yes 11 Do you have to stop for breath when walking at your own pace on level ground *

12. Have you at any time in the last 12 months been woken at night by an attack of shortness of breath? *

Yes 12 Have you at any time in the last 12 months been woken at night by an attack of shortness of breath *

Wheezing and chest tightness

13. Have you had attacks of wheezing or whistling in your chest at any time in the last 12 months? *

Yes 13 Have you had attacks of wheezing or whistling in your chest at any time in the last 12 months *

14. Have you ever had attacks of shortness of breath with wheezing? *

Yes 14 Have you ever had attacks of shortness of breath with wheezing *

15. If Yes, was your breathing absolutely normal between attacks? *

Yes 15 If Yes, was your breathing absolutely normal between attacks *

Smoking

16. Do you or did you smoke more than one cigarette/day; a cigar/week; two oz. pipe tobacco/month)? *

Yes 16 Do you or did you smoke more than one cigarette/day; a cigar/week; two oz. pipe tobacco/month) *

17. Do (did) you inhale smoke? *

If yes, indicate:

Slightly
Moderately
Deeply

18. How old were you when you started smoking regularly? *

19. Do (did) you smoke manufactured cigarettes? *

20. How many cigarettes do (did) you smoke per day on weekdays? *

21. How many per day on weekends? *

22. Do (did) you smoke plain or filtered cigarettes? *

23. What brands do (did) you usually smoke? *

24. Do (did) you smoke hand rolled cigarettes? *

25. How much tobacco do (did) you usually smoke per week in this way? *

26. Do (did) you put filters in these cigarettes? *

27. Do (did) you smoke a pipe? *

28. How much tobacco do (did) you usually smoke per week in this way? *

29. Do (did) you smoke cigars? *

30. How many of these do (did) you usually smoke per week in this way? *

31. If you are a present smoker have you been cutting down in the past year? *

32. If you are a past smoker when did you give up smoking altogether? *

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 isocyanate 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 *

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Date *

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EMPLOYEES HEALTH

Health Monitoring Questionnaire | Spirometry

General Health Questionnaire

Specific Health Questions

Respiratory questionnaire

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