occupational exposure with asthma questionnaire life style

Appendix 1_Occupational Exposure with Asthma Questionnaire

APPENDIX 1 OCCUPATIONAL EXPOSURE WITH ASTHMA QUESTIONNAIRE CLINIC/INSTITUTE ___________________________________________________________ DATE OF EXAMINATION ___/___/______ NAME/or Nr. ___________________________________________________________________ DATE OF BIRTH ___/___/______ (MONTH/DAY/YEAR) /OR

AGE ___ YEARS

SEX F___ M ___ HEIGHT (cm) ______ WEIGHT (kg) ______

LIFE STYLE 1. CURRENT SMOKER: YES ___ NO ___ NEVER SMOKED ___ WHEN DID YOU START SMOKING? DATE: ___/___/______ (MONTH/ YEAR) EX-SMOKER: YES ___ NO ___ DATE QUIT: ___/___/______ (MONTH/ YEAR) SMOKING HISTORY # CIGARETTS ___ per DAY 2. FOOD/DIET INTOLERANCE?___________ ALLERGY?___________ 3. USE OF ALCOHOLIC BEVERAGES THE NEXT QUESTIONS ARE ABOUT DRINKING ALCOHOLIC BEVERAGES. WHEN I USE THE WORD 'DRINK' IT MEANS: - ONE BOTTLE OR CAN OF BEER OR A GLASS OF DRAFT - ONE GLASS OF WINE OR A WINE COOLER - ONE DRINK OR COCKTAIL WITH 1 ½ OUNCES OF LIQUOR DURING THE PAST 12 MONTHS, HAVE YOU HAD A DRINK OF BEER, WINE, LIQUOR OR ANY OTHER ALCOHOLIC BEVERAGE? YES ___ NO ___

1 X Baur/Anamnese/Exposure to Toxic Chemicals /Asthma/2007


EXPOSURE/OCCUPATIONAL HISTORY 1. JOB DESCRIPTION __________________________________________________________________ 2. SINCE WHEN ARE YOU WORKING IN YOUR CURRENT JOB? ___ (M)/ ______ (Y) 3. DO YOU HAVE CURRENTLY CONTACT WITH TOXIC DUST, FUMEs, ALLERGENS, IRRITATING GASES OR CHEMICALS? YES ___ NO ___ 4. REGULARY? YES ___ NO ___ 5. IF YES TO QUESTION # 3, SPECIFY: ……………………………………………………… -------------------------------------------------------------------------------------------------------------___ ____________________________ (OTHER) ___ ____________________________ (SOLVENTS)

I. II.

DURATION OF EXPOSURE IN TOTAL ______ (MONTHS) HOW MANY HOURS DO YOU HAVE CONTACT WITH THE AGENTS MENTIONED ABOVE PER WEEK? ___ HOURS III. WHEN WAS THE LAST EXPOSURE? ___/___/______ (MONTH/DAY/YEAR) IV. DURATION OF LAST EXPOSURE ____ (DAYS) ____ (HOURS) ____ (MINUTES) 6. IF NO (QUESTION # 3): DID YOU WORK WITH THESE AGENTS IN THE PAST? YES ___ NO ___ WHICH AGENT? _______________________________________________________ WHAT WAS YOUR JOB DESCRIPTION AT THAT TIME? _________________________ EXPOSURE STARTED (DATE) ___/______ (MONTH/YEAR) EXPOSURE ENDED (DATE) ___/______ (MONTH/YEAR) 7. WHILE WORKING DID YOU USE ANY PROTECTION EQUIPMENT? YES ___ NO ___ IF YES: WHICH? ______________________________________________________________

OCCUPATIONAL ASTHMA QUESTIONNAIRE 8. IS THERE PREVIOUS OR CURRENT EXPOSURE TO IRRITANTS OR POTENTIAL SENSITIZERS AT WORK? YES ___ NO ____ LIST OTHER AGENTS ENCOUNTERED AT WORK: __________________________________________________________________ __________________________________________________________________ WHILE WORKING WITH THE AGENT, HAVE YOU EXPERIENCED ANY OF THE FOLLOWING SYMPTOMS? WHEEZING? YES _______ NO ________ COUGH? YES _______ NO ________ SHORTNESS OF BREATH? YES _______ NO ________ 2 X Baur/Anamnese/Exposure to Toxic Chemicals /Asthma/2007


IF YES TO ITEM 8 ANSWER THE FOLLOWING QUESTIONS: SYMPTOMS BEGAN HOW MANY HOURS AFTER BEGINNING THE WORKSHIFT? _________#HOURS HOW MANY HOURS DO SYMPTOMS LAST AT WORK?_____#HOURS DID SYMPTOMS CONTINUE AFTER COMPLETION OF THE WORKSHIFT? IF SO, HOW MANY HOURS? _______#HOURS DID THE SYMPTOMS IMPROVE ON WEEKENDS? YES ___ NO____ DID THE SYMPTOMS IMPROVE ON VACATIONS? YES___NO ___ ON WHAT DATE DID THE ABOVE SYMPTOMS START? ___/_____/_______ ON WHAT DATE DID THE ABOVE SYMPTOMS END? ___/_____/_______ ARE THE ABOVE SYMPTOMS STILL PRESENT? YES ___ NO ____ DURATION OF EXPOSURE BEFORE ONSET OF SYMPTOMS: ______________ (MONTHS, YEARS) DURATION OF SYMPTOMS AT THE TIME OF DIAGNOSIS: _______________ (MONTHS, YEARS) WHILE WORKING WITH THIS AGENT, HAVE YOU EXPERIENCED ANY OF THE FOLLOWING SYMPTOMS? FEVER? YES _______ NO _______ CHILLS? YES _______ NO _______ MUSCLE ACHES? YES _______ NO _______ IF YES TO ITEM 5, ANSWER THE FOLLOWING QUESTIONS: SYMPTOMS BEGAN HOW MANY HOURS AFTER BEGINNING THE WORKSHIFT? _________#HOURS HOW MANY HOURS DO SYMPTOMS LAST AT WORK? _____#HOURS DID SYMPTOMS CONTINUE AFTER COMPLETION OF THE WORKSHIFT? IF SO, HOW MANY HOURS? _______#HOURS DID THE SYMPTOMS IMPROVE ON WEEKENDS? YES ___ NO____ DID THE SYMPTOMS IMPROVE ON VACATIONS? YES___NO ___ ON WHAT DATE DID THE ABOVE SYMPTOMS START? ___/_____/_______ ON WHAT DATE DID THE ABOVE SYMPTOMS END? ___/_____/_______ ARE THE ABOVE SYMPTOMS STILL PRESENT? YES ___ NO ____ DURATION OF EXPOSURE BEFORE ONSET OF SYMPTOMS: ______________ (MONTHS, YEARS) DURATION OF SYMPTOMS AT THE TIME OF DIAGNOSIS: _______________ (MONTHS, YEARS) WHILE WORKING WITH THIS SUBSTANCE, HAVE YOU EXPERIENCED ANY OF THE FOLLOWING SYMPTOMS? SNEEZING? YES _______ NO _______ 3 X Baur/Anamnese/Exposure to Toxic Chemicals /Asthma/2007


RUNNY NOSE? ITCHY EYES? DERMATITIS?

YES _______ NO _______ YES _______ NO _______ YES _______ NO _______

IF YES TO ITEM 6, ANSWER THE FOLLOWING QUESTIONS: SYMPTOMS BEGAN HOW MANY HOURS AFTER BEGINNING THE WORKSHIFT _________#HOURS HOW MANY HOURS DO SYMPTOMS LAST AT WORK? _____#HOURS DID SYMPTOMS CONTINUE AFTER COMPLETION OF THE WORKSHIFT? IF SO, HOW MANY HOURS? _______#HOURS DID THE SYMPTOMS IMPROVE ON WEEKENDS? YES ___ NO____ DID THE SYMPTOMS IMPROVE ON VACATIONS? YES___NO ___ ON WHAT DATE DID THE ABOVE SYMPTOMS START? ___/_____/_______ ON WHAT DATE DID THE ABOVE SYMPTOMS END? ___/_____/_______ ARE THE ABOVE SYMPTOMS STILL PRESENT? YES ___ NO ____ DURATION OF EXPOSURE BEFORE ONSET OF SYMPTOMS: ______________ (MONTHS, YEARS) DURATION OF SYMPTOMS AT THE TIME OF DIAGNOSIS: _______________ (MONTHS, YEARS)

9. DO YOU COUGH ON MOST DAYS FOR AT LEAST 3 MONTHS OUT OF THE YEAR? YES ______ NO _______ 10. HAVE YOU EVER BEEN DIAGNOSED WITH ASTHMA? YES ____ NO____ IF YES, AT WHAT AGE WERE YOU DIAGNOSED? _____YRS 11. ARE YOU CURRENTLY BEING TREATED FOR ASTHMA? IF YES, ANSWER THE FOLLOWING QUESTIONS: LIST REGULAR ASTHMA MEDICATIONS IN THE PAST 3 MONTHS? NAME OF DRUG(S) INHALED -AGONISTS: YES __ NO ____ __________________________________ INHALED STEROIDS: YES ___ NO___ (UG/DAY? _____ ) ____________________ ORAL PREDNISONE: YES ____NO ___ (MG/DAY? ____ ) ____________________ # OF ASTHMA ATTACKS/WEEK REQUIRING ß-AGONIST

________

# OF NIGHTS/WEEK AWAKENING FOR ASTHMA SYMPTOMS _______ # OF NIGHTS/MONTH AWAKENING FOR ASTHMA SYMPTOMS _______ # OF ASTHMA FLARES REQUIRING PREDNISONE BURST IN LAST 3 MONTHS? _______ LAST 12 MONTHS? ______ 4 X Baur/Anamnese/Exposure to Toxic Chemicals /Asthma/2007


12. HAVE YOU EVER BEEN DIAGNOSED WITH EMPHYSEMA OR CHRONIC BRONCHITIS? YES ____ NO _____ 13. DO YOU HAVE ITCHY EYES, RUNNY AND CONGESTED NOSE DURING SPRING, SUMMER OR FALL ON A YEARLY BASIS? YES _______ NO ________ IF YES, WHEN? (CIRCLE) MARCH > APRIL

MAY > JUNE

AUGUST > SEPTEMBER

14. RESULTS OF SKIN PRICK TESTS TO AEROALLERGENS (check below if skin prick test positive defined as a wheal of at least 3 mm greater than saline control) WHEAL/FLARE (MM) DUST MITE SHORT RAGWEED ALTERNARIA CAT GRASS POLLEN TREE POLLEN OTHER

______/______ ______/______ ______/______ ______/______ ______/______ ______/______ ______/______

SERUM TOTAL IGE (IF AVAILABLE)

______________ ______________ ______________ ______________ ______________ ______________ ______________

______ KU/L)

15. IF PATIENT HAS CURRENT ASTHMA, ASSESS SEVERITY ACCORDING TO THE INTERNATIONAL WHO GUIDELINES (CIRCLE ONE) MILD

MILD PERSISTENT MODERATE

SEVERE

--------------------------------------------------------------------------------------------------------------------16. LUNG FUNCTION MEASUREMENTS SPIROMETRY FINDINGS AT INITIAL EVALUATION (DATE):____/______/_______ FEV1 pre _______ L post BD ______ L % improvement ______

FVC pre ____________ L post BD____________L % improvement ________

METHACHOLINE PC20 ________ (mg/ml) MONITORING OF FEV1 IN THE WORKPLACE: Done _____ Not done ____ If done: Positive ___ Negative _______



Changes in PC20 for period at work and away from work: Suggestive ____ Non-suggestive ______ Changes in PEF for period at work and away from work: Suggestive ____Non-suggestive ____ SPECIFIC INHALATIVE CHALLENGE TEST RESULT DATE……………AGENT?.....................RESULT………….. ------------------------------------------------------------------------------------------------------------------------------------17. FINAL ASSESSMENT to be completed by Physician (check all that apply) Occupational asthma due to a specific agent at work: Name suspect or proven agent: __________________________________________________________ Reactive airways dysfunction syndrome (RADS) ______ Occupational rhinitis _____; suspected causes ______ Asthma caused by common aeroallergens/Non-occupational asthma or COPD due to______ _______________________________________________________ Allergic rhinitis due to causes outside the workplace: ________ Non-allergic rhinitis of unknown causation ________ Hypersensitivity pneumonitis: ________ Other diagnoses or details:

__________________________________

PHYSICIAN EVALUATOR (attach additional information if needed): _________________________________________________

DATE: ______/______/_____

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