OCCUPATIONAL HISTORY NAME: DATE: Date of Birth: day month year Current Job Title/ Employer: Type of Industry: Length of Time at Current Job: Employment Status: Full time Regular Hours Regular Duties Ο Ο Ο Part-time Modified Hours Modified Duties Ο Ο Ο Do you undergo any routine medical at work? Yes No Ο Ο If yes one(s) and why? (silica, lead, isocyanates, asbestos, other) Hearing tests Chest x-rays Pulmonary Function Tests Ο Ο Ο Bloods tests Other Ο Ο Do you wear Personal Protective Equipment? Yes No Ο Ο If yes, which one(s): Gloves Coveralls Safety Glasses Hearing Protection Ο Ο Ο Ο Mask Respirator Safety Shoes Other_ Ο Ο Ο Ο if you are exposed to any of the following: Fumes Animals Loud Noises Ο Ο Ο Dust Vibration Extreme Heat/Cold Ο Ο Ο Chemicals Radiation Pesticides Ο Ο Ο Solvents Nanofibers Metal Working Fluids Ο Ο Ο Repetitive movement/lifting OTHER Ο Ο Do you think that any aspect of your health is aggravated by your work? Yes No Ο Ο Please list any other jobs you have had in the past, include dates (years), title and your job description (welding, painting, etc.) DATES EMPLOYER JOB TITLE JOB DESCRIPTION
OCCUPATIONAL HISTORY NAME: DATE: Date of Birth: day month year Current Job Title/ Employer: Type of Industry: Length of Time at Current Job: Employment Status: Ο Full time Ο Regular Hours Ο Regular Duties Ο Part-time Ο Modified Hours Ο Modified Duties Do you undergo any routine medical at work? Yes Ο No Ο If yes one(s) and why? (silica, lead, isocyanates, asbestos, other) Ο Hearing tests Ο Chest x-rays Ο Pulmonary Function Tests Ο Bloods tests Ο Other Do you wear Personal Protective Equipment? Yes Ο No Ο If yes, which one(s): Ο Gloves Ο Coveralls Ο Safety Glasses Ο Hearing Protection Ο Mask Ο Respirator Ο Safety Shoes Ο Other_ if you are exposed to any of the following: Ο Fumes Ο Animals Ο Loud Noises Ο Dust Ο Vibration Ο Extreme Heat/Cold Ο Chemicals Ο Radiation Ο Pesticides Ο Solvents Ο Nanofibers Ο Metal Working Fluids Ο Repetitive movement/lifting Ο OTHER Do you think that any aspect of your health is aggravated by your work? Ο Yes Ο No Please list any other jobs you have had in the past, include dates (years), title and your job description (welding, painting, etc.) DATES EMPLOYER JOB TITLE JOB DESCRIPTION
occupational_history_for_physicians__final_master_2016___6_.docx