Medical Evaluation Questionnaire for Occupational Lead Exposure By
the Massachusetts Division of Occupational Safety Name:____________________________________ Nationality: ________________________________ Country of Birth: _______________________________ Medicare / Medicaid / Social Security #____________________________ Date of birth:_______________________________ Male __________ Female _________ Employer: __________________________________________________ Employer's
address:___________________________________________ Contact person: ____________________________ Phone: _________________________ Address
to send results to: _____________________________________ Phone: _________________________ Other
employer(s) in past year: __________________________________ Exposure History Past lead-related employers and hobbies (dates / years worked, country): ____________________________________________________________ ______________________________________________________________ _______________________________________________________________ Description of current job: __________________________________________ __________________________________________________________ Job tasks in past year (check all that apply) _____Ironwork:
cutting/burning/welding painted surfaces _____Painting / brushing with lead paint____ Spray painting with lead paint _____paint applications: applying lead paint as a powder _____Lead paint containment: erecting/removing barriers or covers _____paint removal: __dry scraping __chemical removal __power sanding _____burning _____ abrasive blasting _____cleanup: ___sweeping ___standard vacuum ___HEPA vacuum _____Battery manufacturing / recycling _____Lead soldering ____Lead smelting _____ Foundry work _____Radiator repair _____Metal machining or grinding _____Wire or cable manufacture _____Plastics / PVC manufacture _____Scrap metal recycling_________Ammunition manufacture _____Demolition______Other lead work (specify)_______________________ Other possible current or recent exposures: ____Leadlighting / Stained glass ____ Pottery /ceramics ____ Folk medicines: _____Ayurvedic medicine_____Chinese herbal medicine________Other (specify)____________________________________________________ ____Firing range use or maintenance ____Making bullets or shot ______Making fishing sinkers_______Home or other building renovation ______Furniture or mirror renovation_______Burning painted wood _________Home car maintenance______Home auto paint renovation _______Regular use of hair colour restorer or other leaded cosmetics _________Regular use of pewter for_______food or ________drink. Specify the food or drink and the frequency:___________________________________ _________Regular use of crystal for________food or _______drink. Specify the food or drink and the frequency:__________________________________ ________Regular ingestion of turmeric. Specify frequency: _______________ _______Regular ingestion of imported canned foods (specify)______________ ______Regular ingestion of Chinese preserved eggs. Specify frequency: _____ Comments (eg favourite foods if unusual): _____________________________ ______________________________________________________________ Protective measures Respirator: (check those used) _____Dust mask (disposable) _____Standard canister (negative-pressure) respirator _____Negative-pressure respirator, with HEPA filter _____Powered air-purifying respirator _____Supplied-air respirator
Current Symptoms Y N Comments Weight loss ____________________________________________ Fatigue _______________________________________________ Poor sleep _____________________________________________ Metallic taste in mouth_____________________________________ Loss of appetite _________________________________________ Abdominal pain _________________________________________ Nausea/vomiting _________________________________________ Pain in teeth ____________________________________________ Constipation ___________________________________________ Irritability ______________________________________________ Headaches _____________________________________________ Memory problems _______________________________________ Difficulty concentrating ___________________________________ Hearing loss ____________________________________________ Numbness
or tingling of Joint pain ______________________________________________ Change in sex drive ______________________________________ (Women)
Change in Other _________________________________________________ Past Medical History Y N Comments Have you ever had: High blood pressure ______________________________________________ Kidney disease __________________________________________________ Anemia/low blood count ____________________________________________ Heart disease ___________________________________________________ Asthma ________________________________________________________ Emphysema ____________________________________________________ Bronchitis ______________________________________________________ Gout __________________________________________________________ Arthritis ________________________________________________________ Head injury _____________________________________________________ Depression _____________________________________________________ Difficulty conceiving a child ________________________________________ A
child with a birth defect (Women) Miscarriage ______________________________________________ Social and Family History Do any children live in your home? _____Yes _____No. If Yes, Ages, Male / Female:_____________________________________________ When was your home built (if known)? __________ Is there any lead paint in it? ____Yes ____ No ____ Don't know Do you smoke cigarettes? ____Yes ____No If Yes, packs per day ____________Brand:____________, or Bagged loose tobacco:__________ Has alcohol ever been a problem for you? _____Yes _____No When was your last drink? __________ Physical Examination Height_____ Weight _____ BP_____ P_____ Normal Abnormal Comment HEENT (lead line optic disc) ________________________________________ Heart ___________________________________________________________ Lungs __________________________________________________________ Abdomen _______________________________________________________ Cranial nerves ___________________________________________________ Motor strength (esp wrist extensors)__________________________________ Sensory (esp distal) _______________________________________________ Coordination ____________________________________________________ Affect __________________________________________________________ Orientation (place, person, time) _____________________________________ Memory (object recall) _____________________________________________ Attention (serial 7s) _______________________________________________ Visual-spatial (design copying) ______________________________________ Laboratory tests ordered: Whole blood lead _____ ZPP _____ Hgb _____ Hct _____ MCV _____ Smear __________________ BUN _____ Creat _____ U/A ____________________________ Iron studies_____________________________________________ Other __________________________________________________ Optional tests: Sperm analysis __________ Pregnancy test __________ Nerve conduction velocity __________ Medical Evaluation for Lead Exposure Results and Recommendations (copy to employer and employee) Name:__________________________________ Date of birth: ____________ Date of evaluation:_______________ Blood lead level:_______ Any condition detected which increases risk from exposure to lead? ____Yes ____No. Specify:_________________________________________________ Duty status: _____Continued duty _____Continued duty, but review of protective measures _____Medical removal from lead exposure, with wage protection* _____Medical removal and chelation therapy** Respirator use: _____No restrictions on use _____Use with following accommodations: ____________________________ _____Not approved for respirator use Follow-up:_____Follow-up medical evaluation in _____ days / weeks*** _____Follow-up blood lead test in _____ days / weeks / months**** _____Lead test dust wipes____at workplace____at home____at hobby location _____Blood lead test co-workers ______co-habitants______child co-habitants Nutritional intervention: ____________________________________________ |
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