Work Care Clinic
Salt Lake City
Orem
Draper
Layton
2390 South Redwood Rd.
Salt Lake City, UT 84119
Phone: (801) 975-1600
Fax: (801) 975-1666
601 North 1200 West
Orem, UT 84057
Phone: (801) 224-4211
Fax: (801) 226-3482
12422 South 450 East
Draper, Utah 84020
Phone: (801) 748-1600
Fax: (801) 748-1601
2102 N. 1700 W. #103
Layton, Utah 84041
Phone: (801) 773-3400
Fax: (801) 773-3401
HAZMAT EXAM
Name
Sex:
Male Female
Home Address
City
Phone: Home
State
Zip
Work
Cell
Social Security Number
Date of Birth
Emergency Contact: Name
Phone
JOB PROFILE
Job Title, current or proposed:
Date of Hire
Name of Employer:
Work
Schedule:
% Field
% Office
% Travel
Address:
Job Duty: Briefly describe your current or anticipated job duties, including any hazards
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Physical Requirements: please list any physical demands such as heavy lifting, pushing, pulling, handling heavy tools or equipment, etc.
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Protective Equipment: mark if used at all, and what part of the time per day it is used.
0-2 Hours
2-4 Hours
4-6 Hours
6-8 Hours
> 8 Hours
Respirator
SCBA
Gloves
Coveralls or aprons
Safety glasses
Hearing protection
Other
EMPLOYMENT HISTORY
Please list all jobs ever held, starting with your most recent, not including your current job.
Name of Employer
From:
To: Mo/yr
Job Title or Description of Work
Mo/yr
Military History: have you ever served in the military?
If Yes:
Branch:
Location(s):
Position/Job:
Dates:
Potential Hazards
Yes No
Mark Anderson, M.D., ALL RIGHTS RESERVED
1
SOCIAL HISTORY
Do you currently smoke cigarettes?
Yes No
If yes, How many total years have you smoked?
Do you use any of the following tobacco products:
Do you drink
Yes
alcoholic beverages?
No
Did you smoke cigarettes in the past?
Yes No
How many packs per day, on average?
Pipes Cigars
Chewing Tobacco
If yes, average # of drinks, beers
or glasses of wine per week:
Snuff
WORK RELATED HEALTH PROBLEMS
Please answer yes or no, and explain all yes answers in the space below.
YES
NO
1.
2.
3.
4.
5.
6.
Have you ever changed jobs because of occupational hazards or dangers?
Have you ever been injured on the job?
Have you ever had an illness or disease that was caused by work?
Have you ever lost time from work for a work related injury or illness?
Have you ever been exposed or been treated for exposure to a chemical?
Have you ever been exposed or been treated for exposure to radiation?
a. Do you now or have you previously worn a radiation badge?
b. Has the reading on your badge ever come back high?
7. Have you ever been exposed to a biological agent?
8. Have you ever had a rash or skin lesion secondary to a chemical?
9. Have you ever had a chemical burn or foreign body injury to the eye?
10. Have you ever worked with substances that caused lung, nose or sinus irritation?
10. Have you ever had a serious animal, spider or snake bite?
11. Do you currently work a second job?
12. Do you handle explosives?
13. Are you exposed to any toxic substances at home, on other jobs, hobbies or away from work?
Please provide a detailed explanation to all yes answers above:
TOXIC EXPOSURE HISTORY
Please indicate below any substances you have come in direct contact with either currently or in the past.
Now
FUMES and DUSTS
Asbestos
Plastic Fumes
Welding Fumes
Fiberglass
Silica or Sand
Wood Dust
Coal Dust
Portland Cement
Mica
Other:
METALS
Aluminum
Antimony
Arsenic
Past
Never
Now
Past
Never
Barium
Cadmium
Chromium
Cobalt
Copper
Gold
Lead
Manganese
Mercury
Nickel
Silver
Uranium
Zinc
Other:
Mark Anderson, M.D., ALL RIGHTS RESERVED
2
TOXIC EXPOSURE HISTORY-CONTINUED
Now
Past
Never
SOLVENTS
Now
Past
Never
Pesticides
Vinyl Chloride
Dyes
Other:
Acetone
Alcohols
Benzene, Toluene, Xylene
Carbon Tetrachloride
Epoxy Resins
Ethylene Glycol
Methyl Ethyl Ketone
Paint, Varnish, Degreasers
Perchlorethylene
Trichloroethylene
Methylene Chloride
Other:
Other:
PETROLEUM PRODUCTS
Asphalt
Coal Tar Pitch
Kerosene
Naphtha
Petroleum Ether
Other:
OTHER CHEMICALS
Acrylamide, Acrylonitrile
Ammonia
Acids
Alkali
Formaldehyde
PCBs
GASES
Carbon Monoxide
Chlorine Gas
Ethylene Oxide
Hydrogen Sulfide
Cyanide
Sulfur Dioxide
Other:
RADIATION
X-Ray exposure
Radiation Waste
Radioactive Isotopes
Microwave
Ultraviolet, Infrared
Other:
MISCELLANEOUS
Heavy Lifting
Excessive Heat or Cold
Emotional Stress
Biologicals
Noise
Ergonomic Hazards
Vibration
Other:
Please describe any other exposures or concerns you have regarding potential exposures:
MEDICAL HISTORY
Check any of the following that you now have or ever had.
1.
2.
3.
4.
5.
6.
7.
8.
Aids/HIV
Alcohol or drug problems
Allergies
Anemia or blood disorders
Asthma
Back or neck injury or problems
Bone or joint problems, arthritis
Broken bones
9. Bursitis or tendonitis
10. Cancer, tumor or growth
11. Carpal tunnel syndrome
12. Chest pain or pressure
13.Cough, chronic or frequent
14. Dental problems
15. Depression or anxiety
16. Diabetes
17. Dizziness or fainting spells
18. Ear, nose or throat trouble
19. Emphysema
20. Epilepsy or seizures
21. Eye problems or disorders
27. Hepatitis
28. Hernia or rupture
29. High blood pressure
30. Infertility or difficulty conceiving
31. Kidney or bladder problems
32. Liver disease
33. Lung disease or pneumonia
34. Meningitis
22. Headaches, frequent or severe
23. Head injury, loss of consciousness
24. Hearing loss
25. Heart attack or heart surgery
26. Heart disease or heart murmur
35. Mental or nervous disorders
36. Skin disease
37. Stomach problems or ulcers
38. Thyroid disorder
39. Tuberculosis
Are you currently being treated for illness or injury?
Have you been treated for persistent illness or injury?
Please list all hospitalizations and surgeries
Year
Yes
Yes
No
No
Reason
Mark Anderson, M.D., ALL RIGHTS RESERVED
3
TESTS AND IMMUNIZATIONS
Please list dates of most recent test or immunization
Yes/Date
No
Don’t
know
Tetanus
TB skin test
Polio
Measles,Mumps,Rubella
Hepatitis A
Hepatitis B
Small Pox
Yes/Date
No
Don’t
know
Chest X-Ray
Electrocardiogram (EKG)
Hearing Test
Pulmonary function test
Other
Other
MEDICATIONS
List all medications you take, prescription and over the counter.
______________________
________________________
List any medication allergies.
____________________________
__________________
__________________
__________________
_______________________
_______________________
_______________________
____________________
____________________
____________________
REPRODUCTIVE HISTORY
Yes
No
Not applicable
1. Are you currently pregnant?
2. Have you experienced any problems or complications with pregnancy?
3. Have you or your spouse (or partner) had difficulty in becoming pregnant?
Explain yes answers:
OTHER MEDICAL PROBLEMS
Yes
No
1. Do you have any other health problems that the above questions have missed?
If yes, please list:
2. In your opinion, what are your most important health problems? List as many as you can
I certify that the answers to the foregoing questions are complete and accurate to the best of my knowledge.
Signature:
Date:
Mark Anderson, M.D., ALL RIGHTS RESERVED
4
PHYSICAL EXAMINATION
Name:
SS#
Weight:
Height:
Urinalysis:
Vision
Blood Pressure:
Spec. Grav:
Pulse:
Glucose:
Far Vision
Uncorrected
Date
Blood:
Near Vision
Corrected
Uncorrected
Resp:
Protein:
Color Vision
Corrected
Pass
Fail
Right
How tested:
Left
Depth Perception:
Physical
Normal
Abnormal
Not
Done
Normal
Head, Face and Scalp
Abdomen
Eyes
G-U System
Ears
Spine
Nose and Sinuses
Upper Extremities
Mouth and Throat
Lower Extremities
Neck//Thyroid
Vascular System
Lymphatics
Neurological
Lungs and Chest
Mental Status
Heart
Skin
Abnormal
Not
Done
Testing
Normal
Abnormal
Not
Done
Normal
EKG
Audiogram
Pulmonary Function Testing
Chest X-ray
Abnormal
Not
Done
Examiner’s Diganoses and Comments: (restate all abnormal findings)
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Examiner Name:
Examiner Signature:
Mark Anderson, M.D., ALL RIGHTS RESERVED
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