Appendix
Baseline Questionnaire (Medical student version)
‘Questionnaire on Occupational Allergy in Medical Doctors’
Demographic Information
Name:
(Last
) (First
) (Middle
Identification Number of Medical School: (
Gender:
1. Male
2. Female
Date of Birth: (Day
Age:
(
)
)
(please circle one)
/Month
/Year 19
)
)
Address: (
)
Telephone Number: (
)
Completion date of this questionnaire: (Day
/Month
/Year 19
)
( I ) Health Status
1. Personal history of allergic diseases
Have you ever been experienced these allergic diseases?
If ‘yes,’ please complete the age of physician-diagnosed for each applicable disease.
Bronchial asthma
1. No
2. Yes
(
) years old
Allergic rhinitis and/or Pollen allergy
1. No
2. Yes
(
) years old
Sinusitis
1. No
2. Yes
(
) years old
Eczema
1. No
2. Yes
(
) years old
Urticaria
1. No
2. Yes
(
) years old
Allergic conjunctivitis
1. No
2. Yes
(
) years old
Atopic dermatitis
1. No
2. Yes
(
) years old
2. Height and Weight
Please complete your height and weight.
Height
(
) cm
Weight (
) kg
( II ) Family History of Allergic Diseases
Do you have family members who have already experienced these diseases?
If ‘yes,’ please list the family members specifically for each applicable disease (e.g. father, mother, brother,
sister).
Bronchial asthma
1. No
2. Yes (please specify
)
Allergic conjunctivitis
1. No
2. Yes
(please specify
)
Allergic rhinitis and/or Pollen allergy
1. No
2. Yes (please specify
)
1
Sinusitis
1. No
2. Yes (please specify
)
Atopic dermatitis
1. No
2. Yes (please specify
)
Urticaria
1. No
2. Yes (please specify
)
Eczema
1. No
2. Yes (please specify
)
( III ) Life-style
1. Smoking habit
a. Have you ever been a smoker?
If you are ‘Ex-smoker’ or ‘Current smoker’, please complete your smoking duration and average number
of cigarettes smoked per day.
1. Never smoked
2. Ex-smoker
Smoking duration (from
years old to
Average number of cigarettes (
years old)
/day)
3. Current smoker
Smoking duration (from
years old)
Average number of cigarettes (
/day)
b. Have you ever had other members of your household who have been a smoker?
If ‘yes,’ please list the members specifically (e.g. grandfather, grandmother, father, mother, brother, sister,
husband, wife) .
1. No
2. Yes (please specify
)
2. Living environment
a. Have you ever had domestic animals? If ‘yes,’ please list your animal species.
1. No
Indoor:
2. Yes
1. Cat
2. Dog
3. Bird
4. Fish
5. Others (please specify
)
Outdoor: 1. Cat
2. Dog
3. Bird
4. Fish
5. Others (please specify
)
b. Please indicate your living location before medical school student.
1. Residential zone
2. Business zone
3. Industrial zone
4. Agricultural zone
5. Others (please specify
)
3. Physical activity
a. How many times do you take an exercise?
1. 3-4 times/week
2. 1-2 times/week
3. 1-2 times/month
2
4. none or less than above
b. How many hours per day do you take an exercise?
c. What kind of an exercise do you take?
(
) hours
(please specify
)
4. Eating habits
a. How many times do you take prepared foods, such as retort-packed food, delicatessen, instant soup
noodle, and frozen food?
1. almost none
2. 1-3 times/week
3. 4-6 times/week
4. 1 time/day
5. 2 times/day
6. 3 times/day
b. How often do you take these foods?
1. eggs (
/week)
2. milk (
l/week)
3. bananas (
/month)
4. mangoes and/or avocados (
/year)
c. Were you a breast-fed baby?
1. Yes
2. No
d. How often do you eat breakfast?
1. almost every day
2. not every day
e. Are there any kinds of food that you do not eat? If ‘yes,’ please list the foods specifically.
(please specify
)
5. Hobby
What is your hobby? And please complete the tools and materials for your hobby.
Hobby (
) Tools and materials (
)
Example:
Hobby
Tools and materials
Plastic model
Adhesive solvent, Paint
Bonsai
Insecticide, Pesticide
Mountain climbing
No tools for mountain climbing
(IV) Self Reported Allergic Symptoms
1. Respiratory symptoms
a. Have you ever experienced wheezing or whistling in the chest when you have not had a cold or flu?
3
If ‘yes,’ please complete the age of your first attack.
1. Yes (
years old )
2. No
IF YOU ANSWERED ‘NO,’ PLEASE SKIP TO QUESTION 2 (Dermal symptoms).
b. Please indicate the season in which your respiratory symptoms most frequently appeared.
1. Spring
2. Summer
3. Autumn
4. Winter
5. Non-related to season
c. Please indicate the changes in your respiratory symptoms up to now.
1. worsen
2. unchanged
3. remitted
4. completely disappeared (cured)
2. Dermal symptoms
a. Have you ever experienced suddenly reddish skin, itching or oozing? If ‘yes,’ please complete the age
of your first such episodes.
1. Yes (
years old )
2. No
IF YOU ANSWERED ‘NO,’ PLEASE SKIP TO QUESTION 2c.
b. Please indicate the changes in your dermal symptoms up to now.
1. worsen
2. unchanged
3. remitted
4. completely disappeared (cured)
c. Have you ever experienced eczema caused by rubber gloves?
1. Yes
2. No
d. Have you ever experienced eczema caused by metallic accessories, such as pierced earrings, earrings,
and wrist watches? If ‘yes,’ please list the caused items specifically.
1. Yes (please specify
)
2. No
e. Have you ever experienced eczema caused by cosmetics, shampoos, soaps or hairdressings?
If ‘yes,’ please list the caused items specifically.
1. Yes (please specify
)
2. No
3. Nasal symptoms
a. Have you ever experienced frequently sneezing, nasal discharge or nasal obstruction when you have not
had a cold or flu? If ‘yes,’ please complete the age of your first such episodes.
1. Yes (
years old )
2. No
4
IF YOU ANSWERED ‘NO,’ PLEASE SKIP TO QUESTION 4 (Ocular symptoms).
b. Please indicate the change in your nasal symptoms up to now.
1. worsen
2. unchanged
3. remitted
4. completely disappeared (cured)
c. Please indicate the months in which your nasal symptoms most frequently appear.
1. all the year round and almost unchanging
2. all the year round and especially worsen in the specific months of the year
please list all the specific months; (Jan, Feb, Mar, Apr, May, Jun, Jul, Aug, Sep, Oct, Nov, Dec)
3. only in the specific months
please list all the specific months; (Jan, Feb, Mar, Apr, May, Jun, Jul, Aug, Sep, Oct, Nov, Dec)
4. unspecific
4. Ocular symptoms
a. Have you ever experienced eye itching, reddish eyes or a watery eyes? If ‘yes,’ please complete the age
of your first such episodes.
1. Yes (
years old)
2. No
IF YOU ANSWERED ‘NO,’ PLEASE QUIT THIS QUESTIONNAIRE.
b. Please indicate the changes in your ocular symptoms up to now.
1. worsen
2. unchanged
3. remitted
4. completely disappeared (cured)
c. Please indicate the months in which your ocular symptoms most frequently appeared.
1. all the year round, almost unchanging
2. all the year round, especially worsen in the specific months of the year
please list all the specific months; (Jan, Feb, Mar, Apr, May, Jun, Jul, Aug, Sep, Oct, Nov, Dec)
3. only in the specific months
please list all the specific months; (Jan, Feb, Mar, Apr, May, Jun, Jul, Aug, Sep, Oct, Nov, Dec)
4. unspecific
5
Follow-up Questionnaire
‘Questionnaire on Occupational Allergy in Medical Doctors’
Demographic Information
Name:
(Last
Former Name:
) (First
(
)
(Middle
)
)
Identification Number of medical school: (
)
Year of entrance into the medical school: (19
)
Year of graduation from the medical school: (
)
Telephone Number (home): (
); (office): (
Fax Number (office): (
)
)
E-Mail Address: (
)
Completion date of this questionnaire: (Day
/Month
/Year 20
)
( I ) Smoking Habit
Have you ever been a smoker? If you are ‘Ex-smoker’ or ‘Current smoker,’ please complete your smoking
duration and average number of cigarettes smoked per day.
1. Never smoked
2. Ex-smoker
Smoking duration (from
years old to
Average number of cigarettes (
years old)
/day)
3. Current smoker
Smoking duration (from
years old):
Average number of cigarettes (
/day)
( II ) Self Reported Allergic Symptoms
1. Respiratory symptoms
a. Have you ever experienced wheezing or whistling in the chest when you have not had a cold or flu?
(1) Yes
(2) No
IF YOU ANSWERED ‘NO,’ PLEASE SKIP TO QUESTION 2 (Dermal symptoms).
b. Please indicate the changes in your respiratory symptoms up to now.
(1) newly emerged after your graduation
(2) continue and get worsened after your graduation
(3) unchanged
(4) remitted or completely disappeared after your graduation
c. Please answer the following questions about work-related nature in your respiratory symptoms.
(1) Do you think that your symptoms seem to be related to your work?
Yes (
)
No (
)
e.g. The symptoms appeared on your workplace, and decreased or disappeared at home. The
6
symptoms appeared at the days on duty (e.g. weekdays), and decreased or disappeared during
the days off duty (e.g. weekends, holidays). The symptoms disappeared after a change of your
workplace or profession.
(2) Have you ever experienced the respiratory symptoms by use of specific medical items, such as
chemical substances, medical tools and medical materials? If ‘yes’ and you are aware of the triggered
items, please list the items specifically.
Yes (please specify
)
No (
)
e.g. latex gloves, disinfectants [chlorhexidine gluconate solution (Hibitane®), povidone-iodine
(Isodine®), ethanol]
(3) Have you ever experienced the respiratory symptoms by laboratory animals? If ‘yes’ and you are
aware of the triggered animal species, please list the animal species specifically.
Yes (please specify
)
No (
)
(4) Have you ever experienced the respiratory symptoms related to your medical activity (e.g. stress)
without specification to causative substances?
Yes (
)
No (
)
(5) Have you ever experienced the respiratory symptoms by other causes or relations above
mentioned? If ‘yes’ and you are aware of these, please complete specifically.
Yes (please specify
) No (
)
2. Dermal symptoms
a. Have you ever experienced suddenly reddish skin, itching or oozing?
(1) Yes
(2) No
IF YOU ANSWERED ‘NO,’ PLEASE SKIP TO QUESTION 3 (Nasal symptoms).
b. Please indicate the changes in your dermal symptoms up to now.
(1) newly emerged after your graduation
(2) continue and get worsened after your graduation
(3) unchanged
(4) remitted or completely disappeared after your graduation
c. Please answer the following questions about work-related nature in your dermal symptoms.
(1) Do you think that your symptoms seem to be related to your work?
Yes (
)
No (
)
e.g. The symptoms appeared on your workplace, and decreased or disappeared at home. The
symptoms appeared at the days on duty (e.g. weekdays), and decreased or disappeared during
the days off duty (e.g. weekends, holidays). The symptoms disappeared after a change of your
workplace or profession.
(2) Have you ever experienced the dermal symptoms by use of specific medical items, such as
chemical substances, medical tools and medical materials? If ‘yes’ and you are aware of the
triggered items, please list the items specifically.
Yes (please specify
)
No (
)
e.g. latex gloves, disinfectants [chlorhexidine gluconate solution (Hibitane®), povidone-iodine
7
(Isodine®), ethanol]
(3) Have you ever experienced the dermal symptoms by laboratory animals? If ‘yes’ and you are
aware of the triggered animal species, please list the animal species specifically.
Yes (please specify
)
No (
)
(4) Have you ever experienced the dermal symptoms related to your medical activity (e.g. stress)
without specification to causative substances?
Yes (
)
No (
)
(5) Have you ever experienced the dermal symptoms by other causes or relations above mentioned?
If ‘yes’ and you are aware of these, please complete specifically.
Yes (please specify
)
No (
)
3. Nasal symptoms
a. Have you ever experienced frequently sneezing, nasal discharge or nasal obstruction when you have not
had a cold or flu?
(1) Yes
(2) No
IF YOU ANSWERED ‘NO,’ PLEASE SKIP TO QUESTION 4 (Ocular symptoms).
b. Please indicate the changes in your nasal symptoms up to now.
(1) newly emerged after your graduation
(2) continue and get worsened after your graduation
(3) unchanged
(4) remitted or completely disappeared after your graduation
c. Please answer the following questions about work-related nature in your nasal symptoms.
(1) Do you think that your symptoms seem to be related to your work?
Yes (
)
No (
)
e.g. The symptoms appeared on your workplace, and decreased or disappeared at home. The
symptoms appeared at the days on duty (e.g. weekdays), and decreased or disappeared during
the days off duty (e.g. weekends, holidays). The symptoms disappeared after a change of your
workplace or profession.
(2) Have you ever experienced the nasal symptoms by use of specific medical items, such as
chemical substances, medical tools and medical materials? If ‘yes’ and you are aware of the
triggered items, please list the items specifically.
Yes (please specify
)
No (
)
e.g. latex gloves, disinfectants [chlorhexidine gluconate solution (Hibitane®), povidone-iodine
(Isodine®), ethanol]
(3) Have you ever experienced the nasal symptoms by laboratory animals? If ‘yes’ and you are
aware of the triggered animal species, please list the animal species specifically.
Yes (please specify
)
No (
)
(4) Have you ever experienced the nasal symptoms related to your medical activity (e.g. stress)
without specification to causative substances?
Yes (
)
No (
)
8
(5) Have you ever experienced the nasal symptoms by other causes or relations above mentioned?
If ‘yes’ and you are aware of these, please complete specifically.
Yes (please specify
) No (
)
4. Ocular symptoms
a. Have you ever experienced eye itching, reddish eyes or a watery eyes?
(1) Yes
(2) No
IF YOU ANSWERED ‘NO,’ PLEASE SKIP TO QUESTION III.
b. Please indicate the changes in your ocular symptoms up to now.
(1) newly emerged after your graduation
(2) continue and get worsened after your graduation
(3) unchanged
(4) remitted or completely disappeared after your graduation
c. Please answer the following questions about work-related nature in your ocular symptoms.
(1) Do you think that your symptoms seem to be related to your work?
Yes (
)
No (
)
e.g. The symptoms appeared on your workplace, and decreased or disappeared at home. The
symptoms appeared at the days on duty (e.g. weekdays), and decreased or disappeared during
the days off duty (e.g. weekends, holidays). The symptoms disappeared after a change of your
workplace or profession.
(2) Have you ever experienced the ocular symptoms by use of specific medical items, such as
chemical substances, medical tools and medical materials? If ‘yes’ and you are aware of the
triggered items, please list the items specifically.
Yes (please specify
)
No (
)
e.g. latex gloves, disinfectants [chlorhexidine gluconate solution (Hibitane®), povidone-iodine
(Isodine®), ethanol]
(3) Have you ever experienced the ocular symptoms by laboratory animals? If ‘yes’ and you are
aware of the triggered animal species, please list the animal species specifically.
Yes (please specify
)
No (
)
(4) Have you ever experienced the ocular symptoms related to your medical activity (e.g. stress)
without specification to causative substances?
Yes (
)
No (
)
(5) Have you ever experienced the ocular symptoms by other causes or relations above mentioned?
If ‘yes’ and you are aware of these, please complete specifically.
Yes (please specify
)
No (
)
( III ) Occupational History as a Medical Doctor
Please fill in the table below about all departments up to now in which you have ever worked for, work
duration and job contents in each department following the example.
9
Example:
Department
1
2
Work duration
Doctor-in-training 3 months in each department
Surgery
Job contents
basic training for medical examination and
(2 years as a total)
treatment
2 years
medical examination, treatment and
operation
3
Basic medicine
1 year
experiment using laboratory animals in an
experimental facility (up to now)
Your occupational history as a medical doctor
Department
Work duration
Job contents
1
2
3
4
5
6
7
10