GENERAL HEALTH ASSESSMENT (if applicable) Symptoms of: Comments Further testing? Skin disorders Yes No Headaches, dizziness Yes No Respiratory disorders Yes No Irritation of eyes, nose or Yes No throat Cough Yes No CNS Yes No Peripheral nervous Yes No system symptoms Others: Yes No Pregnant Yes No Breastfeeding Yes No Smoker Yes No Height _____cm Weight _____kg Bp ____/____ mmHg OTHER MEDICAL HISTORY, FAMILY MEDICAL HISTORY, CURRENT MEDICATION, COMMENTS, TESTS OR RECOMMENDATIONS (use separate sheet if necessary)
GENERAL HEALTH ASSESSMENT (if applicable) Symptoms of: Comments Further testing? Skin disorders Yes No Headaches, dizziness Yes No Respiratory disorders Yes No Irritation of eyes, nose or throat Yes No Cough Yes No CNS Yes No Peripheral nervous system symptoms Yes No Others: Pregnant Breastfeeding Smoker Yes No Yes No Yes No Yes No Height _____cm Weight _____kg Bp ____/____ mmHg OTHER MEDICAL HISTORY, FAMILY MEDICAL HISTORY, CURRENT MEDICATION, COMMENTS, TESTS OR RECOMMENDATIONS (use separate sheet if necessary)
hazardous-chemicals-requiring-health-monitoring.docx