Comparative Medicine, University of Dublin Trinity College
OCCUPATIONAL HEALTH QUESTIONNAIRE
Please make an appointment to attend at the College Health Centre
to have the respiratory check done (ext 1556) There is a fee for this service
Please ensure that you have filled in all the information BEFORE
attending at the clinic
CONFIDENTIAL
______________________________________
_________________________
Surname
Forename
________/________/________
Date of Birth
Address
___________________________________________________________
___________________________________________________________
_______________
Telephone (Work)
Your Height:
___________________
Telephone (Home)
_____________
Mobile
Your weight:
Department Address
Present Job Title
All medical information will be kept in strictest confidence by the college
Occupational Health service . To maintain your confidentiality, your employer or
supervisor must not look at or review your answers and your employer must tell you
how to deliver or send this questionnaire to the health care professional who will
review it.
Please advise if you like to talk to the health care professional who will review this
questionnaire about your answers to this questionnaire: Yes / No
Comparative Medicine, University of Dublin Trinity College
OCCUPATIONAL HEALTH – RESPIRATORY QUESTIONNAIRE
PLEASE READ THE FOLLOWING QUESTIONS CAREFULLY AND TICK THE
APPROPRIATE YES/NO BOX
Cough
1
2
3
Do you usually cough first thing in the morning or on getting
up? (Count a cough with first smoke or on first going out of
doors. Exclude throat clearing or single cough.)
If Yes-Do you cough like this on most days for as much as three
months each year?
Do you cough at work?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Are you disabled from walking by any physical disability?
i.e muscular problems/arthritis/paralysis/other
Yes
No
Are you troubled by shortness of breath, when hurrying on the
level or walking up a slight hill?
Yes
No
Yes
No.
Yes
No
If yes-is the cough related to anything in particular at work?
Phlegm (sputum)
4
Do you usually bring up any phlegm/sputum from your chest
first thing in the morning or on getting up?
(Count phlegm with first smoke or on first going out of doors.
Exclude phlegm from the nose. Count swallowed phlegm).
5
6
7
8.
If Yes-Do you bring up phlegm like this on most days for as
much as three months each year?
In the past three years, have you had a period of coughing and
phlegm lasting three weeks or more? If the answer is Yes
proceed to question 7
How many such episodes of prolonged sputum production (for
more than 3 weeks at a time), have you had in the last 3 years?
Have you ever coughed up blood? If “yes” please advise how
often this has happened and when?
Breathlessness
9
10.
11.
12.
13
14
Does your chest ever feel tight or your breathing become
difficult?
Do you get this apart from with colds and flu?
If “Yes”, specify:
With exercise
At work
Other
Always present
Do you get short of breath walking with other people of your
own age on level ground?
Do you have to stop for breath when walking at your own pace
on level ground?
Comparative Medicine, University of Dublin Trinity College
Wheezing
15
Does your chest ever sound wheezy or whistling?
(If “No”, Ignore questions 14-18 and go straight to question 19)
Yes
No
Yes
No
Yes
No
Have you ever had attacks of shortness of breath with wheezing?
(If “No” – leave out question 18)
Yes
No
Is/was you’re breathing absolutely normal between these
attacks?
Yes
No
Yes
No
Yes
No
Yes
No
16
Do you get this wheezy or whistling on most days or nights?
17
Do you get this wheezy or whistling apart from colds?
If “Yes”, specify:
With exercise
At work
Always
Other, please specify:
18
19
Nasal Catarrh
20
Do you usually have a stuffy nose or catarrh at the back of your
nose in the winter?
Occupation
21
Have you ever worked in a dusty job or been exposed to
gases/chemicals or fumes at work?
If “Yes”, please specify where you have worked:
--------------------------------------------------------------------------------------------------------------------------------------------------------
22
Have you ever kept poultry, pigeons, budgerigars, or any other
member of the parrot family?
Medical Information
Have you ever had:
25
(Give relevant details after each positive answer)
An injury or operation affecting your chest?
26
Heart trouble?
27
Bronchitis?
28
Pneumonia?
29
Pleurisy?
30
Pulmonary Tuberculosis (TB)?
31
Bronchial Asthma?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Comparative Medicine, University of Dublin Trinity College
32
Hay Fever/allergic rhinitis or sinusitis?
33
Any other chest disease?
Yes
No
Yes
No
Yes
No
34
An injury or operation affecting your chest?
35
Have you any allergies? If “YES” please specify:
Yes
No
36
Have you ever had an inhaler to treat a lung or breathing
problem?
Yes
No
Have you ever received a course of oral steroid tablets to treat a
lung or breathing problem?
Yes
No
Have any famiily members a history of asthma, eczema,
dermatitis or allergies?
Yes
No
Yes
No
Yes
No
37
38
Smoking
33
34
Do you smoke?
(Record “Yes” if regular smoker up to one month ago)
Have you ever smoked?
If the answers to Questions 33 and 34 on smoking are “No” do not complete the
following three questions.
35
How old were you when you started smoking regularly?
36
Do/did you inhale the smoke
Years
of age
Yes
37
No
Amount currently smoked or that was smoked in the past –
average (including weekends):
Cigarettes:
------------
Per day
Hand rolled cigarettes:
------------
oz per day
Pipe:
------------
oz per day
Cigars
------------
per week
------------
Year
FOR EX SMOKERS
When did you last give up smoking?
Comparative Medicine, University of Dublin Trinity College
DECLARATION
I declare that all the answers contained in this Health Questionnaire are, to the best of
my knowledge, true. I consent to the results of the Health Surveillance being sent to
my General Practitioner if it is clinically indicated. I consent to anonymous group
results of the Health Surveillance being sent to my employer
Employee Signature: ___________________________________
Date:
Did you have any difficulty in completing this form?
(If “Yes”, please specify)
Yes
No
Name and address of your GP:
Thank you for your co-operation
EXAMINATION - Occupational Health Staff use only
Name
Date of birth
Employer name
Height
Weight
Blood Pressure
Spirometry Result
Chest Xray if indicated
Result
Yes
Physical Examination:
Respiratory Rate:
Chest expansion: cm/ins
Percussion
Auscultation: Breath sounds/Air entry/Any additional sounds (creps/rhonchi)
Any rhonchi on forced expiration?
No
Comparative Medicine, University of Dublin Trinity College
CVS examination:
Opinion:
Details sent to GP
Letter sent to Employee (date):
Yes
/
/
Letter sent to Employer (date):
/ /
(general report only – copy in Company file)
Name and Qualifications of Examiner:
DATE OF NEXT REVIEW:
Signature
Date:
/
/
No