ATS-DLD-78-A | | ADULT QUESTIONNAIRE - SELF COMPLETION | | (for those 13 years of age and older) | | Thank you for your

willingness to participate. You were selected | | by a scientific sampling procedure, and your cooperation is very | | important to the success of this study. | | This is a questionnaire you are asked to fill out. Please answer | | the questions as frankly and accurately as possible. ALL INFORMATION | | OBTAINED IN THE STUDY WILL BE KEPT CONFIDENTIAL AND USED FOR MEDICAL | | RESEARCH ONLY. Your personal physician will be informed about the test | | results if you desire. | |----------------------------------------------------------------------------| IDENTIFICATION IDENTIFICATION NUMBER: ##### NAME:_________________________ (Last) ________________________ ___ (First) (MI)

STREET ______________________________________________________ CITY ____________________________ PHONE NUMBER: ( INTERVIEWER: ### DATE: ___________________ MO DAY YR ============================================================================= = 1. 2. 3. 4. BIRTHDATE: _____ Month ____ Day ______ Year STATE ____ ZIP _______

) ______-__________

Place of Birth: _______________________________ Sex: What is your marital status? 1. Male ____ 2. Female ____ 1. 2. 3. 4. Single ____ Married ____ Widowed ____ Separated/Divorced ____

5.

Race:

1. 2. 3. 4.

White ____ Black ____ Oriental ____ Other ____

What is the highest grade completed in school? __________ (For example: 12 years is completion of high school) ============================================================================= = SYMPTOMS These questions pertain mainly to your chest. Please answer yes or no if possible. If a question does not appear to be applicable to you, check the does not apply space. If you are in doubt about whether your answer is yes or no, record no. COUGH 7A. Do you usually have a cough? ___ (Count a cough with first smoke or on first going out-of-doors. Exclude clearing of throat.)[If no, skip to question 7C.] B. Do you usually cough as much as 4 to 6 times a ___ day, 4 or more days out of the week? C. Do you usually cough at all on getting up, or ___ first thing in the morning? D. Do you usually cough at all during the rest ___ of the day or at night? IF YES TO ANY OF THE ABOVE(7A,7B,7C, OR 7D), ANSWER THE FOLLOWING: IF NO TO ALL, CHECK DOES NOT APPLY AND SKIP TO 8A. E. Do you usually cough like this on most days for ___ 5 consecutive months or more during the year? 8. Does not apply __ F. For how many years have you had this cough? ____________________ Number of years 88. Does not apply __ ============================================================================= === PHLEGM 1. Yes ___ 2. No 1. Yes ___ 2. No 1. Yes ___ 2. No 1. Yes ___ 2. No

6.

1. Yes ___ 2. No

8A. Do you usually bring up phlegm from your chest? ___ (Count phlegm with the first smoke or on first going out-of-doors. Exclude phlegm from the nose. Count swallowed phlegm) [If no, skip to 8C.] B. Do you usually bring up phlegm like this as ___ much as twice a day, 4 or more days out of the week? C. Do you usually bring up phlegm at all on get___ ting up or first thing in the morning? D. Do you usually bring up phlegm at all during ___ the rest of the day or at night? IF YES TO ANY OF THE ABOVE (8A, B, C, OR D), ANSWER THE FOLLOWING: IF NO TO ALL, CHECK DOES NOT APPLY AND SKIP TO 9A. E. Do you bring up phlegm like this on most days ___ for 3 consecutive months or more during the year? __ F. For how many years have you had trouble with ____________________ phlegm? __

1. Yes ___ 2. No

1. Yes ___ 2. No

1. Yes ___ 2. No

1. Yes ___ 2. No

1. Yes ___ 2. No 8. Does not apply

Number of years 88. Does not apply

============================================================================= = EPISODES OF COUGH AND PHLEGM 9A. Have you had periods or episodes of (in___ creased*) cough and phelgm lasting for 3 weeks or more each year? *(For individuals who usually have cough and/or phlegm) IF YES TO 9A: B. For how long have you had at least 1 such ____________________ episode per year? __ 1. Yes ___ 2. No

Number of years 88. Does not apply

============================================================================= = WHEEZING 10A. Does your chest ever sound wheezy or whistling: 1. When you have a cold? ___ 2. Occaisonally apart from colds? ___ 3. Most days or nights? ___ IF YES TO 1, 2, OR 3 IN 10A: B. For how many years has this been present? ____________________ Number of years 88. Does not apply __ 11A. Have you ever had an ATTACK of wheezing that ___ has made you feel short of breath? IF YES TO 11A: B. How old were you when you had your first years such attack? __ C. Have you had 2 or more such episodes? ___ 8. Does not apply __ D. Have you ever required medicine or treatment ___ for the(se) attack(s)? __ ============================================================================= = BREATHLESSNESS 12. If disabled from walking by any condition other than heart or lung disease, please describe and proceed to Question 14A. 8. Does not apply 1. Yes ___ 2. No _______ Age in 88. Does not apply 1. Yes ___ 2. No 1. Yes ___ 2. No

1. Yes ___ 2. No 1. Yes ___ 2. No 1. Yes ___ 2. No

Nature of condition(s):__________________________________________________ 13A. Are you troubled by shortness of breath when

hurrying on the level or walking up a slight hill? ___ IF YES TO 13A: B. Do you have to walk slower than people of your ___ age on level because of breathlessness? __ C. Do you ever have to stop for breath when walk___ ing at your own pace on the level? __ D. Do you ever have to stop for breath after walk ___ ing about 100 yards(or after a few minutes) on __ the level? E. Are you too breathless to leave the house or ___ breathless on dressing or undressing? __

1. Yes ___ 2. No

1. Yes ___ 2. No 8. Does not apply 1. Yes ___ 2. No 8. Does not apply 1. Yes ___ 2. No 8. Does not apply

1. Yes ___ 2. No 8. Does not apply

============================================================================= = CHEST COLDS AND CHEST ILLNESSES 14A. If you get a cold, does it usually go to your ___ chest? (Usually means more than 1/2 the time) colds__ 15A. During the past 3 years, have you had any ___ chest illnesses that have kept you off work, indoors at home, or in bed? IF YES TO 15A: B. Did you produce phlegm with any of these ___ chest illnesses? __ C. In the last 3 years, how many such illnesses, illnesses with (increased) phlegm, did you have which lasted a week or more? _____Number of _____No such illnesses _____Does not apply 8. Does not apply 1. Yes ___ 2. No 1. Yes ___ 2. No 8. Don't get 1. Yes ___ 2. No

============================================================================= = PAST ILLNESSES

16. ___ 17. ___

Did you have any lung trouble before the age of 16? Have you ever had any of the following: 1A. Attacks of Bronchitis? IF YES TO 1A: B. Was it confirmed by a doctor?

1. Yes ___ 2. No

1. Yes ___ 2. No

1. Yes ___ 2. No 8. Does not apply

___ __ C. At what age was your first attack? years 88. Does not apply __ 2A. Pneumonia (include bronchopneumonia)? ___ IF YES TO 2A: B. Was it confirmed by a doctor? ___ 8. Does not apply __ C. At what age did you first have it? years 88. Does not apply __ 3A. Hayfever? ___ IF YES TO 3A: B. Was it confirmed by a doctor? ___ 8. Does not apply __ C. At what age did it start? years 88. Does not apply __ 18A. Have you ever had chronic bronchitis? ___ IF YES TO 18A: B. Do you still have it? ___ 8. Does not apply __ 1. Yes ___ 2. No ______ Age in 1. Yes ___ 2. No 1. Yes ___ 2. No ______ Age in 1. Yes ___ 2. No 1. Yes ___ 2. No ______ Age in

1. Yes ___ 2. No

C. Was it confirmed by a doctor? ___ __ D. At what age did it start? years __ 19A. Have you ever had emphysema? ___ IF YES TO 19A: B. Do you still have it? ___ __ C. Was it confirmed by a doctor? ___ __ D. At what age did it start? years __ 20A. Have you ever had asthma? ___ IF YES TO 20A: B. Do you still have it? ___ __ C. Was it confirmed by a doctor? ___ __ D. At what age did it start? years __ E. If you no longer have it, at what age did it stop? __ 21. Have you ever had:

1. Yes ___ 2. No 8. Does not apply ______ Age in 88. Does not apply 1. Yes ___ 2. No

1. Yes ___ 2. No 8. Does not apply 1. Yes ___ 2. No 8. Does not apply ______ Age in 88. Does not apply

1. Yes ___ 2. No

1. Yes ___ 2. No 8. Does not apply 1. Yes ___ 2. No 8. Does not apply ______ Age in 88. Does not apply ______ Age stopped 88. Does not apply

A. Any other chest illnesses? ___ If yes, please specify ____________________________________________ B. Any chest operations? ___ If yes, please specify ____________________________________________ C. Any chest injuries? ___ If yes, please specify ____________________________________________ 22A. ___ Has doctor ever told you that you had heart trouble? IF YES to 22A: B. Have you ever had treatment for heart trouble ___ in the past 10 years? __ 23A. ___ Has a doctor ever told you that you have high blood pressure? IF YES to 23A: B. Have you had any treatment for high blood ___ pressure (hypertension) in the past 10 years? __

1. Yes ___ 2. No

1. Yes ___ 2. No

1. Yes ___ 2. No

1. Yes ___ 2. No

1. Yes ___ 2. No 8. Does not apply 1. Yes ___ 2. No

1. Yes ___ 2. No 8. Does not apply

============================================================================= = OCCUPATIONAL HISTORY 24A. ___ Have you ever worked full time (30 hours per week or more) for 6 months or more? IF YES to 24A: B. Have you ever worked for a year or more in ___ any dusty job? __ Specify job/industry: _________________________ Total years worked __ Was dust exposure 1. Mild ___ 2. Moderate ___ 3. Severe ___ ? 8. Does not apply 1. Yes ___ 2. No 1. Yes ___ 2. No

C. Have you ever been exposed to gas or chemical ___ fumes in your work? __

1. Yes ___ 2. No 8. Does not apply

Specify job/industry: _________________________ Total years worked __ Was dust exposure 1. Mild ___ 2. Moderate ___ 3. Severe ___ ? D. What has been your usual occupation or job -- the one you have worked at the longest? 1. Job-occupation: __________________________________________________ 2. Number of years employed in this occupation:______________________ 3. Position-job title: ______________________________________________ 4. Business, field, or industry: ____________________________________ ============================================================================= = TOBACCO SMOKING 25A. ___ Have you ever smoked cigarettes? (NO means less than 20 packs of cigarettes or 12 oz. of tobacco in a lifetime or less than 1 cigarette a day for 1 year. IF YES to 25A: B. Do you now smoke cigarettes (as of 1 month ___ ago)? __ C. How old were you when you first started regYears cigarette smoking? __ D. If you have stopped smoking cigarettes comstopped pletely, how old were you when you stopped? ___ 88.Does not apply __ E. How many cigarettes do you smoke per day now? __ F. On the average of the entire time you smoked, ___ Cigarettes/day ___ Cigarettes/day 88.Does not apply Check if still smoking ____ Age 88.Does not apply ____ Age in 8. Does not apply 1. Yes ___ 2. No 1. Yes ___ 2. No

how many cigarettes did you smoke per day? __ G. Do or did you inhale the cigarette smoke? __ ______

88.Does not apply 1. Does not apply 2. Not at all 3. Slightly

________ 4. Moderately ______ 5. Deeply __________ 26A. ___ Have you ever smoked a pipe regularly? (YES means more than 12 oz tobacco in a lifetime.) IF YES to 26A: B1. How old were you when you started to smoke a pipe regularly? 2. If you have stopped smoking a pipe comstopped pletely, how old were you when you stopped? ____ 88.Does not apply __ C. On the average over the entire time you stansmoked a pipe, how much pipe tobacco did conyou smoke per week ? __ D. How much pipe tobacco are you smoking now? week 88. Not currently smoking a pipe ___ E. Do or did you inhale the pipe smoke? ____ 2. Not at all ______ 3. Slightly ________ 4. Moderately ______ 5. Deeply __________ 1. Never smoked ___ oz per tains 1 1/2 oz) 88.Does not apply dard pouch of tobacco ____ oz per week (a Check if still smoking pipe ____ Age ____ Age 1. Yes ___ 2. No

27A. ___

Have you ever smoked cigars regularly? (Yes means more than 1 cigar a week for a year). IF YES to 27A: B1. How old were you when you started smoking cigars regularly? 2. If you have stopped smoking cigars com-

1. Yes ___ 2. No

____ Age ____ Age Check if still smoking 88.Does not apply

stopped pletely, how old were you when you stopped? cigars___ __ C. On the average over the entire time you week smoked cigars, how many cigars did you smoke __ per week ? D. How many cigars are you smoking per week week now? __ E. Do or did you inhale the cigar smoke? ____ 2. Not at all ______ 3. Slightly ________ 4. Moderately ______ 5. Deeply __________ ============================================================================= = FAMILY HISTORY 28. Were either of your natural parents ever told by a doctor that they had a chronic lung condition such as: FATHER 1. YES 2. NO 3. DON'T KNOW 1. YES MOTHER 2. NO 3. DON'T KNOW 1. Never smoked 88. Check if not smoking cigars currently ___ Cigars per 88.Does not apply ___ Cigars per

A. Chronic brochitis?

_____

_____

_______

_____

_____

_______

B. Emphysema? C. Asthma?

_____ _____

_____ _____ _____ _____

_______ _______ _______ _______

_____ _____ _____ _____

_____ _____ _____ _____

_______ _______ _______ _______

D. Lung cancer? _____ E. Other chest conditions? _____

29A.

Is parent currently alive? _____ _____

_______

_____

_____

_______

B. Please Specify: _____ Age if living _____ Age at death 8. Don't know _____ C. Please specify cause of death. ________________________________ _____ Age if living _____ Age at death 8. Don't know _____ _________________________

Initial Questionnaire of the NIOSH Occupational Asthma Identification Project

ID #:

INS - AZ - ________________

Location: ___________________________

Date:

____/____/________

**** General Tips before You Start ****

This questionnaire will ask you mainly about your health.

Read the whole question before making an answer.

Try to answer all questions unless you are told to skip them.

If you cannot decide whether to answer YES or NO, leave the question blank.

If there are several responses, select the one which best describes your situation or symptoms, unless you are told to choose multiple answers.

IDENTIFICATION

1) NAME: _________________ (Last)

_______________________ (First)

___________ (Middle Initial)

2) SOCIAL SECURITY #: _________

_____

_________

3) BIRTH DATE: _____/______/_____ (Month/Day/Year)

4) CURRENT ADDRESS: ____________________________________________ (Number, Street, or Rural Route) ____________________________________________

____________________________________________ (City or Town, State, Zip Code)

5) HOME PHONE: (_________) _________ - _________________

6) SEX 1. 2. MALE FEMALE

7) RACE 0. 1. 2. 3. 4. White Black Asian/Pac. Am Ind/Eskimo other

7a) Are you of hispanic origin? 1. 2. NO YES

8) STANDING HEIGHT

9) WEIGHT

__________(inches)

________(lbs)

10) WHAT WAS THE HIGHEST GRADE OF SCHOOL YOU COMPLETED?

__________(years) (Mark 12 if you have a high school diploma, 13 to 15 if you also have technical or associate training, 16 for a college degree, etc.)

11)

This may be the last time we see you, but we would like to be

able to keep you up to date on the results of the study. If you move, is there someone who would know your new address? (For example: parents, child, friend)

NAME: ___________________________ RELATIONSHIP: _________________

ADDRESS: ____________________________________________ (Number, Street, or Rural Route) ____________________________________________ (City or Town, State, Zip Code)

PHONE NUMBER: (_________) _________ - _________________

ABOUT YOUR HEALTH

1.

Have you ever had asthma?

1. 2.

NO YES

2.

Have you ever had an asthmatic attack?

1. 2.

NO YES

IF YOU ANSWERED NO TO BOTH QUESTIONS 1 AND 2, SKIP TO QUESTION NUMBER 3

IF YOU ANSWERED "YES" TO EITHER OF THE ABOVE, PLEASE ANSWER QUESTIONS 2a, 2b and 2c.

2a)

About what age did the asthma start?

__________ age in years or

____ don't know

2b)

Was asthma confirmed by a doctor?

1. 2.

NO YES

2c)

Do you still have asthma?

1.

NO:

How old were you when it stopped?

__________ age in years

2.

YES: Do you now take any pills, capsules, or liquids, including non-prescription medications for asthma?

1. 2.

NO YES (List the names: _________________ _________________________________)

3.

Does your chest ever sound wheezing or whistling?

1. 2.

NO YES: If "YES",

3a)

Do you get this only when you have a cold?

1. 2.

NO YES

occasionally apart from cold?

1. 2.

NO YES

most days or nights each week?

1. 2.

NO YES

3b)

Does the wheezing always clear after you cough?

1. 2.

NO YES

4.

Have you ever had attacks of shortness of breath with wheezing or whistling?

1. 2.

NO YES: If "YES", was your breathing absolutely normal between attacks?

1. 2.

NO YES

5.

During the past 12 months, have you had an attack of shortness of breath or coughing that came on when you were just lying in bed or not doing any special effort?

1. 2.

NO YES

6.

During the past 12 months, has your chest ever felt tight for

longer than a minute?

1. 2.

NO YES

7.

During the past 12 months, have you had an attack of shortness of breath or coughing that came on shortly after you stopped exercising?

1. 2.

NO YES

IF YOU ANSWERED NO TO ALL THE QUESTIONS FROM 3 TO 7, THEN SKIP TO QUESTION 19.

IF YOU ANSWERED "YES" TO ANY OF THE QUESTIONS FROM 3 TO 7, PLEASE ANSWER ALL THE FOLLOWING QUESTIONS.

8.

Which of the following best describes your breathing?

1. 2.

I never or only rarely get trouble with my breathing. I get repeated trouble with my breathing, but it always gets completely better.

3.

My breathing is never quite right.

9.

What have been the most troublesome chest symptom or symptoms?

1. 2. 3. 4. 5.

wheezing or whistling attacks of shortness of breath chest tightness attacks of cough other (Specify: _____________________)

Please answer the following questions about your most troublesome chest symptom(s):

10.

About how often have you had these symptoms?

1. 2. 3. 4. 5. 6.

Only once Only a few days ever A few days each year A few days each month A few days each week Usually at least once each day or night

11.

About what age did the symptoms first start?

___________ age in years

12.

About what age did they last occur?

___________ age in years or

____ I still get them.

13.

During the years that you had the chest symptoms, have you ever had a break in your symptoms for as long as a year or more?

1. 2.

NO YES: IF "YES",

13a) Did you always take breathing medications during the breaks in your symptoms?

1. 2.

NO YES

13b) Since your last break, how long have you had the symptoms?

_____________ years

14.

Are/were your symptoms worse during a particular season of the year?

1. 2.

NO, about the same in all seasons YES: IF "YES", which is/was the worst season?

1. 2. 3. 4.

Winter Spring Summer Fall

15.

Are/were your symptoms worse at any particular time of day or night?:

1. 2.

NO, not worse at any particular time of day or night YES: IF "YES", when are/were they worse?

1. 2. 3. 4.

When you first wake up? While at work? After leaving work? While lying in bed?

16.

When you are off work on weekend or vacation, do/did your symptoms get:

1. 2. 3.

no change. better. worse.

17.

After you have returned to work from leave or vacation, do/did your symptoms get:

1. 2. 3.

no change. better. worse.

18.

Regarding the most troublesome chest symptoms mentioned above, are/were they brought on by, or made worse by (choose all that apply):

Contact with animals/pets?

1. 2.

NO YES

Heavy exercise?

1. 2.

NO YES

Plants or pollens

1. 2.

NO YES

Exposure to insects at work?

1. 2.

NO YES

Dusts, gases, or fumes at work?

1. 2.

NO YES

Dusts or fumes in the home?

1. 2.

NO YES

Exposure to tobacco smoke?

1. 2.

NO YES

19.

Do you have any nerve, muscle, or bone problem or heart trouble that makes walking quite difficult for you?

1. 2.

NO YES (please specify: ____________________________ ____________________________)

20.

Are you troubled by shortness of breath when hurrying on level ground or walking up a slight hill?

1. 2.

NO:

IF NO, SKIP TO QUESTION 21.

YES: IF "YES",

20a) Do you get short of breath walking with other people of your own age on level ground?

1. 2.

NO:

IF NO, SKIP TO QUESTION 21.

YES: IF "YES",

20a1)

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

1. 2.

NO YES

21.

Do you usually cough on getting up, or first thing in the morning in the winter?

(Count a cough with first smoke or on first going out-of-doors. Exclude clearing throat or a single cough.)

[usually] means 4 or more days per week

1. 2.

NO YES

22.

Do you usually cough during the day - or at night - in the winter?

(Ignore an occasional cough.)

[usually] means 4 or more days per week

1. 2.

NO YES

IF YOU ANSWERED NO TO BOTH QUESTIONS 21 AND 22, SKIP TO QUESTION 23

IF YOU ANSWERED "YES" TO EITHER OF THE ABOVE, PLEASE ANSWER QUESTIONS 22a and 22b.

22a) Do you cough like this on most days - or nights - for as much as three months during the year?

1. 2.

NO YES

22b) How many years have you coughed like this?

_________

YEARS

23.

Do you usually bring up any phlegm from your chest on getting up, or first thing in the morning in the winter?

(Count phlegm with first smoke or on first going out of doors. Exclude phlegm from the nose. Count swallowed phlegm.)

[usually] means 4 or more days per week

1. 2.

NO YES

24.

Do you usually bring up any phlegm from your chest during the day - or at night - in the winter?

(If twice or more in a day, mark YES.)

[usually] means 4 or more days per week

1. 2.

NO YES

IF YOU ANSWERED NO TO BOTH QUESTIONS 23 AND 24, SKIP TO QUESTION 25.

IF YOU ANSWERED "YES" TO EITHER OF THE ABOVE, PLEASE ANSWER QUESTIONS 24a and 24b.

24a) Do you bring up phlegm like this on most days - or nights for as much as three months during the year?

1. 2.

NO YES

24b) How many years have you brought up phlegm like this?

_________

YEARS

25.

Do you usually have a stuffy nose, or drainage at the back of

your nose?

1. 2.

NO YES

26.

During the past 12 months, have you had two or more episodes of blocked, itchy, or runny nose?

1. 2.

NO YES

IF YOU ANSWERED NO TO BOTH QUESTIONS 25 AND 26, SKIP TO QUESTION 27

IF YOU ANSWERED "YES" TO EITHER OF THE ABOVE, PLEASE ANSWER QUESTIONS 26a thru 26e.

26a) Do you usually have these nose symptoms at any particular time of year?

1. 2.

NO, about the same in all seasons YES: IF "YES", which is the worst season?

1. 2. 3. 4.

Winter Spring Summer Fall

26b) When you have nose symptoms, do you usually have fever, headache, or general body ache?

1. 2.

NO YES

26c) Were these nose symptoms mainly due to one of the following?

1. 2. 3. 4.

cold or flu hay fever other allergies something else (specify:____________________)

26d) At what age did you first notice the nose symptoms?

_______ years in age

26e) Do the nose symptoms seem better or worse when you were away from work, on vacation, sick leave, or a lay-off?

1. 2. 3. 27.

NO, neither better nor worse away from work YES, better away from work YES, worse away from work

During the past 12 months, have your eyes been red, itchy, or watery more than twice?

1. 2.

NO YES

IF YOU ANSWERED NO TO QUESTION 27, SKIP TO QUESTION 28.

IF YOU ANSWERED "YES", PLEASE ANSWER QUESTIONS 27a thru 27f.

27a) Over the past year, about how often have you noticed this?

1. 2. 3. 4.

less than 1 - 2 days altogether less than 7 days less than 30 days more than 30 days

27b) Do you usually have these eye symptoms at any particular time of year?

1. 2.

NO, about the same in all seasons YES: IF "YES", which is the worst season?

1. 2. 3. 4.

Winter Spring Summer Fall

27c) When you have eye symptoms, do you usually have fever, headache, or general body ache?

1. 2.

NO YES

27d) Were these eye symptoms mainly due to one of the following?

1. 2. 3. 4. 5.

contact lenses cold or flu hay fever other allergies something else (specify:______________)

27e) At what age did you first notice the eye symptoms?

_______ years in age

27f) Did/does the eye symptom seem better or worse when you were away from work, on vacation, sick leave, or a lay-off?

1. 2. 3.

NO, neither better nor worse away from work YES, better away from work YES, worse away from work

28.

During the last 12 months, have you had a skin rash, dermatitis, hives, or eczema? [ Mark NO if your skin looks normal or is only dry. ]

1. 2.

NO YES

IF YOU ANSWERED NO TO QUESTION 28, SKIP TO QUESTION 29.

IF YOU ANSWERED "YES", PLEASE ANSWER QUESTIONS 28a thru 28d.

28a) What parts of your body were affected? (Check ( ) all that apply)

AFFECTED BODY PART

Scalp

( )

Trunk

( )

Face or neck

( )

Groin or private part

( )

Hands or arms

( )

Feet or legs

( )

Other (Specify:_____________________________)

28b) Did any of the following substances cause rashes on your skin? (Check ( ) all that apply)

Jewelry

( )

Tapes, glues

( )

Clothing, gloves, shoes, undergarments ( )

Cosmetics, perfume, deodorant, after shave ( )

Hairdyes/colorings

( )

Soaps, detergents

( )

Skin medicine (ointment, lotion, etc.) ( )

Poison ivy/oak

( )

Oils, greases

( )

Solvents

( )

Chemicals

( )

Others (Specify: _________________________________)

28c) At what age did you first notice these skin changes?

_______ years in age

28d) Did/does your skin seem better or worse when you were away from work, on vacation, sick leave, or a lay-off?

1. 2. 3.

NO, neither better nor worse away from work YES, better away from work YES, worse away from work

29.

Have you ever smoked cigarettes regularly?

1. 2.

NO YES

IF YOU ANSWERED NO TO QUESTION 29, SKIP TO QUESTION 30.

IF YOU ANSWERED "YES" TO QUESTION 29, PLEASE ANSWER QUESTIONS 29a thru 29d.

29a) How old were you when you first started smoking cigarettes regularly?

__________ YEARS OLD (AGE)

29b) Do you still smoke cigarettes?

1.

NO:

IF "NO", how old were you when you last gave up smoking?

__________ YEARS OLD (AGE)

2.

YES

29c) During the years that you smoked, did you ever quit for 6 months or more?

1. 2.

NO YES: IF "YES", how long did you quit for altogether?

__________ YEARS

29d) Over the years that you smoked, on the average approximately how many cigarettes per day did you smoke?

__________ Cigarettes per day.

30.

Do you now smoke a pipe or cigar?

1. 2.

NO YES

31.

Since childhood, have you ever had

(Mark an X in appropriate area)

Yes, in the past

Yes, in the present

No

Unknown

Hay fever?

Emphysema?

Tuberculosis?

Bronchitis?

Pneumonia?

Any Allergies to:

Foods?

Metals?

Chemicals?

Medicines?

Dusts?

Animals?

Others? (Specify: ________________________)

32.

Have you seen a doctor for any problem in the past year?

1. 2.

NO YES: (Please specify):____________________________________________

__________________________________________________________________

33.

Do you take any medications, including non-prescription medicine, aside from vitamins?

1. 2.

NO YES: (Please specify):____________________________________________

__________________________________________________________________

ABOUT YOUR FAMILY

INDICATE ANY BLOOD RELATIVES WHO EVER HAD ANY OF THE FOLLOWING: (Do not include relatives by marriage.)

If family history is completely unknown (subject is adopted, etc.), mark this space ( ) and leave the following blank.

(Mark an X in appropriate area)

PROBLEM

PARENTS

GRAND PARENTS

BROTHER/ CHILDREN SISTER

UNKNOWN IN FAMILY

ANY KIND OF ALLERGIES?

Hay Fever

Eczema

Asthma

Sinus Problem

Other Allergies

ANY LUNG DISEASES SUCH AS:

Emphysema?

Tuberculosis?

Chronic Bronchitis?

Pneumonia?

Other lung trouble?