1. NAME______________________________________________________ |
2. SOCIAL | |||||||||
SECURITY# | |||||||||
_____ | _____ | _____ | _____ | _____ | _____ | _____ | _____ | _____ | |
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |
3. CLOCK | |||||||||
NUMBER | |||||||||
_____ | _____ | _____ | _____ | _____ | _____ | ||||
10 | 11 | 12 | 13 | 14 | 15 |
4. PRESENT OCCUPATION________________________________________ |
5. PLANT_____________________________________________________ |
6. ADDRESS___________________________________________________ |
7. __________________________________________________________ |
(Zip Code) |
8. TELEPHONE NUMBER__________________________________________ |
9. INTERVIEWER_______________________________________________ |
10. DATE | ||||||
____________ | _____ | _____ | _____ | _____ | _____ | _____ |
16 | 17 | 18 | 19 | 20 | 21 |
11. Date of Birth | _____ | _____ | _____ | |||
Month | Day | Year | ||||
_____ | _____ | _____ | _____ | _____ | _____ | |
22 | 23 | 24 | 25 | 26 | 27 |
12. Place of Birth ___________________________________________ |
13. Sex | 1. Male | _____ |
2. Female | _____ | |
14. What is your marital status? | 1. Single | _____ |
2. Married | _____ | |
3. Widowed | _____ | |
4. Separated/Divorced | _____ | |
15. Race | 1. White | _____ |
2. Black | _____ | |
3. Asian | _____ | |
4. Hispanic | _____ | |
5. Indian | _____ | |
6. Other | _____ |
16. What is the highest grade completed in school? |
___________________________________________________ |
(For example 12 years is completion of high school) |
OCCUPATIONAL HISTORY |
17A. Have you ever worked |
full time (30 hours |
per week or more) |
for 6 months or more? |
1. Yes ___________________ |
2. No ____________________ |
IF YES TO 17A: |
B. Have you ever worked |
for a year or more |
in any dusty job? |
1. Yes ___________________ |
2. No ____________________ |
3. Does not apply ________ |
Specify job/industry |
__________________________ |
Total Years Worked |
__________________________ |
Was dust exposure: |
1. Mild __________________ |
2. Moderate ______________ |
3. Severe ________________ |
C. Have you ever been |
exposed to gas or |
chemical fumes in |
your work? |
1. Yes ___________________ |
2. No ____________________ |
Specify job/industry |
__________________________ |
Total Years Worked |
__________________________ |
Was 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 ____________________ |
(Record on lines the years in which you have worked |
in any of these industries, e.g. 1960-1969) |
Have you ever worked: | ||
E. In a mine? ....................... | YES _____ | NO _____ |
F. In a quarry?...................... | YES _____ | NO _____ |
G. In a foundry?..................... | YES _____ | NO _____ |
H. In a pottery?..................... | YES _____ | NO _____ |
I. In a cotton, flax or hemp mill.... | YES _____ | NO _____ |
J. With asbestos?.................... | YES _____ | NO _____ |
18. PAST MEDICAL HISTORY | ||
A. Do you consider yourself | ||
to be in good health? | YES _____ | NO _____ |
If “NO” state reason | ||
________________________ | ||
________________________ | ||
B. Have you any defect of | ||
vision? | YES _____ | NO _____ |
If “YES” state nature of | ||
defect__________________ | ||
________________________ | ||
C. Have you any hearing | ||
defect? | YES _____ | NO _____ |
If “YES” state nature of | ||
defect__________________ | ||
________________________ | ||
D. Are you suffering from | ||
or have you ever suffered | ||
from: |
a. Epilepsy (or fits, | ||
seizure, | YES _____ | NO _____ |
convulsions)? | ||
b. Rheumatic fever? | YES _____ | NO _____ |
c. Kidney disease? | YES _____ | NO _____ |
d. Bladder disease? | YES _____ | NO _____ |
e. Diabetes? | YES _____ | NO _____ |
f. Jaundice? | YES _____ | NO _____ |
19. CHEST COLDS AND CHEST ILLNESSES |
19A. If you get a cold, does it |
usually go to your chest? |
(Usually means more than 1/2 the |
time) |
1. Yes________________________________ |
2. No_________________________________ |
3. Don't get colds ___________________ |
20A. During the past 3 years, have you had |
any chest illnesses that have kept |
you off work, indoors at home, or in |
bed? |
1. Yes________________________________ |
2. No_________________________________ |
IF YES TO 20A |
B. Did you produce phlegm with any of |
these chest illnesses? |
1. Yes________________________________ |
2. No_________________________________ |
3. Does not apply_____________________ |
C. In the last 3 years, how many such |
illnesses with (increased) phlegm |
did you have which lasted a week or |
more? |
Number of illnesses___________________ |
No such illnesses_____________________ |
21. Did you have any lung trouble before |
the age of 16? |
1. Yes________________________________ |
2. No_________________________________ |
22. Have you ever had any of the following? |
1A. Attacks of bronchitis? |
1. Yes________________________________ |
2. No_________________________________ |
IF YES TO 1A: |
B. Was it confirmed by a doctor? |
1. Yes________________________________ |
2. No_________________________________ |
3. Does not apply ____________________ |
C. At what age was your first attack? |
Age in years__________________________ |
Does not apply________________________ |
2A. Pneumonia (include |
bronchopneumonia)? |
1. Yes________________________________ |
2. No_________________________________ |
IF YES TO 2A: |
B. Was it confirmed by a doctor? |
1. Yes________________________________ |
2. No_________________________________ |
3. Does not apply_____________________ |
C. At what age did you first have it? |
Age in years__________________________ |
Does not apply _______________________ |
3A. Hay fever? |
1. Yes________________________________ |
2. No_________________________________ |
IF YES TO 3A: |
B. Was it confirmed by a doctor? |
1. Yes________________________________ |
2. No_________________________________ |
3. Does not apply_____________________ |
C. At what age did it start? |
Age in years__________________________ |
Does not apply________________________ |
23A. Have you ever had chronic bronchitis? |
1. Yes________________________________ |
2. No_________________________________ |
IF YES TO 23A: |
B. Do you still have it? |
1. Yes________________________________ |
2. No_________________________________ |
3. Does not apply_____________________ |
C. Was it confirmed by a doctor? |
1. Yes________________________________ |
2. No_________________________________ |
3. Does not apply ____________________ |
D. At what age did it start? |
Age in years__________________________ |
Does not apply________________________ |
24A. Have you ever had emphysema? |
1. Yes________________________________ |
2. No_________________________________ |
IF YES TO 24A: |
B. Do you still have it? |
1. Yes________________________________ |
2. No_________________________________ |
3. Does not apply_____________________ |
C. Was it confirmed by a doctor? |
1. Yes________________________________ |
2. No_________________________________ |
3. Does not apply_____________________ |
At what age did it start? |
Age in years__________________________ |
Does not apply _______________________ |
25A. Have you ever had asthma? |
1. Yes________________________________ |
2. No_________________________________ |
IF YES TO 25A: |
B. Do you still have it? |
1. Yes________________________________ |
2. No_________________________________ |
3. Does not apply_____________________ |
C. Was it confirmed by a doctor? |
1. Yes________________________________ |
2. No_________________________________ |
3. Does not apply ____________________ |
D. At what age did it start? |
Age in years__________________________ |
Does not apply________________________ |
E. If you no longer have it, at what |
age did it stop? |
Age stopped___________________________ |
Does not apply________________________ |
26. Have you ever had: |
A. Any other chest illness? |
1. Yes________________________________ |
2. No_________________________________ |
If yes, please specify________________ |
______________________________________ |
B. Any chest operations? |
1. Yes________________________________ |
2. No ________________________________ |
If yes, please specify________________ |
______________________________________ |
C. Any chest injuries? |
1. Yes _______________________________ |
2. No ________________________________ |
If yes, please specify________________ |
______________________________________ |
27A. Has a doctor ever told you that you |
had heart trouble? |
1. Yes _______________________________ |
2. No ________________________________ |
IF YES TO 27A: |
B. Have you ever had treatment for |
heart trouble in the past 10 years? |
1. Yes________________________________ |
2. No_________________________________ |
3. Does not apply_____________________ |
28A. Has a doctor ever told you that you |
had high blood pressure? |
1. Yes _______________________________ |
2. No ________________________________ |
IF YES TO 28A: |
B. Have you ever had treatment for |
high blood pressure (hypertension) |
in the past 10 years? |
1. Yes _______________________________ |
2. No ________________________________ |
3. Does not apply ____________________ |
29. When did you last have your chest |
X-rayed? |
(Year) |
_____ |
25 |
_____ |
26 |
_____ |
27 |
_____ |
28 |
30. Where did you last have your chest X-rayed (if known)? |
______________________________________________________ |
What was the outcome? |
______________________________________________________ |
FAMILY HISTORY |
31. Were either of your natural parents ever told by a |
doctor that they had a chronic lung condition such as: |
A. Chronic Bronchitis? |
FATHER - 1. Yes _____ 2. No _____ 3. Don't Know _____ |
MOTHER - 1. Yes _____ 2. No _____ 3. Don't Know _____ |
B. Emphysema? |
FATHER - 1. Yes _____ 2. No _____ 3. Don't Know _____ |
MOTHER - 1. Yes _____ 2. No _____ 3. Don't Know _____ |
C. Asthma? |
FATHER - 1. Yes _____ 2. No _____ 3. Don't Know _____ |
MOTHER - 1. Yes _____ 2. No _____ 3. Don't Know _____ |
D. Lung cancer? |
FATHER - 1. Yes _____ 2. No _____ 3. Don't Know _____ |
MOTHER - 1. Yes _____ 2. No _____ 3. Don't Know _____ |
E. Other chest conditions? |
FATHER - 1. Yes _____ 2. No _____ 3. Don't Know _____ |
MOTHER - 1. Yes _____ 2. No _____ 3. Don't Know _____ |
F. Is parent currently alive? |
FATHER - 1. Yes _____ 2. No _____ 3. Don't Know _____ |
MOTHER - 1. Yes _____ 2. No _____ 3. Don't Know _____ |
G. Please Specify |
FATHER - __________ Age if Living |
__________ Age at Death |
__________ Don't Know |
MOTHER - __________ Age if Living |
__________ Age at Death |
__________ Don't Know |
Please specify cause of death |
FATHER - _____________________ |
MOTHER - _____________________ |
COUGH |
32A. 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 32C.] |
1. Yes _______________________ |
2. No ________________________ |
B. Do you usually cough as much |
as 4 to 6 times a day 4 or |
more days out of the week? |
1. Yes _______________________ |
2. No ________________________ |
C. Do you usually cough at all on |
getting up or first thing in |
the morning? |
1. Yes _______________________ |
2. No ________________________ |
D. Do you usually cough at all |
during the rest of the day or |
at night? |
1. Yes _______________________ |
2. No ________________________ |
IF YES TO ANY OF ABOVE (32A, B, C, OR D), ANSWER THE FOLLOWING. |
IF NO TO ALL, CHECK DOES NOT APPLY AND SKIP TO NEXT PAGE. |
E. Do you usually cough like this |
on most days for 3 consecutive |
months or more during the year? |
1. Yes _______________________ |
2. No ________________________ |
3. Does not apply ____________ |
F. For how many years have you |
had the cough? |
Number of Years ______________ |
Does not apply _______________ |
33A. 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 33C) |
1. Yes _______________________ |
2. No ________________________ |
B. Do you usually bring up phlegm |
like this as much as twice a |
day 4 or more days out of the |
week? |
1. Yes _______________________ |
2. No ________________________ |
C. Do you usually bring up phlegm |
at all on getting up or first |
thing in the morning? |
1. Yes _______________________ |
2. No ________________________ |
D. Do you usually bring up phlegm |
at all during the rest of the |
day or at night? |
1. Yes _______________________ |
2. No ________________________ |
IF YES TO ANY OF THE ABOVE (33A, B, C, OR D), ANSWER THE FOLLOWING: |
IF NO TO ALL, CHECK DOES NOT APPLY AND SKIP TO 34A. |
E. Do you bring up phlegm like |
this on most days for 3 |
consecutive months or more |
during the year? |
1. Yes _______________________ |
2. No ________________________ |
3. Does not apply ____________ |
F. For how many years have you |
had trouble with phlegm? |
Number of years ______________ |
Does not apply _______________ |
EPISODES OF COUGH AND PHLEGM |
34A. Have you had periods or |
episodes of (increased*) cough |
and phlegm and lasting for 3 |
3 weeks or more each year? |
*(For persons who usually |
have cough and/or phlegm) |
1. Yes _______________________ |
2. No ________________________ |
IF YES TO 34A |
B. For how long have you had at |
least 1 such episode per year? |
Number of Years ______________ |
Does not apply _______________ |
WHEEZING | ||
35A. Does you chest ever sound | ||
wheezy or whistling | ||
1. When you have a cold? | 1. Yes _____ | 2. No _____ |
2. Occasionally apart from colds? | 1. Yes _____ | 2. No _____ |
3. Most days or nights? | 1. Yes _____ | 2. No _____ |
IF YES TO 1, 2, or 3 in 35A |
B. For how many years has this |
been present? |
Number of Years ______________ |
Does not apply _______________ |
36A. Have you ever had an attack of |
wheezing that has made you |
feel short of breath? |
1. Yes _______________________ |
2. No ________________________ |
B. How old were you when you had |
your first such attack? |
Age in years _________________ |
Does not apply _______________ |
C. Have you had 2 or more such |
episodes? |
1. Yes _______________________ |
2. No ________________________ |
3. Does not apply ____________ |
D. Have you ever required |
medicine or treatment for |
the(se) attacks? |
1. Yes _______________________ |
2. No ________________________ |
3. Does not apply ____________ |
BREATHLESSNESS |
37. If disabled from walking |
by any condition other |
than heart or lung disease, |
please describe and |
proceed to question 39A. |
Nature of condition(s) |
______________________________ |
______________________________ |
38A. Are you troubled by |
shortness of breath when |
hurrying on the level or |
walking up a slight hill? |
1. Yes _______________________ |
2. No ________________________ |
IF YES TO 38A |
B. Do you have a walk slower |
than people of your age |
on the level because of |
breathlessness? |
1. Yes _______________________ |
2. No ________________________ |
3. Does not apply ____________ |
C. Do you ever have to stop |
for breath when walking at |
your own pace on the level? |
1. Yes _______________________ |
2. No ________________________ |
3. Does not apply ____________ |
D. Do you ever have to stop |
for breath after walking |
about 100 yards (or after |
a few minutes) on the level? |
1. Yes _______________________ |
2. No ________________________ |
3. Does not apply_____________ |
E. Are you too breathless to |
leave the house or |
breathless on dressing or |
climbing one flight of |
stairs? |
1. Yes _______________________ |
2. No ________________________ |
3. Does not apply ____________ |
TOBACCO SMOKING |
39A. 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.) |
1. Yes _______________________ |
2. No ________________________ |
IF YES TO 39A |
B. Do you now smoke cigarettes |
(as of one month ago)? |
1. Yes _______________________ |
2. No ________________________ |
3. Does not apply ____________ |
C. How old were you when you |
first started regular |
cigarette smoking? |
Age in years _________________ |
Does not apply _______________ |
D. If you have stopped smoking |
cigarettes completely, how |
old were you when you stopped? |
Age stopped __________________ |
Check if still smoking _______ |
Does not apply _______________ |
E. How many cigarettes do you |
smoke per day now? |
Cigarettes per day ___________ |
Does not apply _______________ |
F. On the average of the entire |
time you smoked, how many |
cigarettes did you smoke per |
day? |
Cigarettes per day ___________ |
Does not apply _______________ |
G. Do or did you inhale the |
cigarette smoke? |
1. Does not apply ____________ |
2. Not at all ________________ |
3. Slightly __________________ |
4. Moderately ________________ |
5. Deeply ____________________ |
40A. Have you ever smoked a pipe |
regularly? (Yes means more |
than 12 oz. of tobacco in a |
lifetime.) |
1. Yes _______________________ |
2. No ________________________ |
IF YES TO 40A: |
B. 1. How old were you when you |
started to smoke a pipe |
regularly? |
Age __________________________ |
2. If you have stopped smoking |
a pipe completely, how old |
were you when you stopped? |
Age stopped __________________ |
Check if still smoking |
pipe _________________________ |
Does not apply _______________ |
C. On the average over the entire |
time you smoked a pipe, how |
much pipe tobacco did you |
smoke per week? |
________ oz. per week (a |
standard pouch |
of tobacco contains |
1 1/2 oz.) |
________ Does not apply |
D. How much pipe tobacco are you |
smoking now? |
oz. per week _________________ |
Not currently smoking |
a pipe________________________ |
E. Do you or did you inhale the |
pipe smoke? |
1. Never smoked ______________ |
2. Not at all ________________ |
3. Slightly __________________ |
4. Moderately ________________ |
5. Deeply ____________________ |
41A. Have you ever smoked cigars |
regularly? (Yes means more |
than 1 cigar a week for a |
year). |
1. Yes _______________________ |
2. No ________________________ |
IF YES TO 41A |
FOR PERSONS WHO HAVE EVER SMOKED CIGARS |
B. 1. How old were you when you |
started smoking cigars |
regularly? |
Age __________________________ |
2. If you have stopped smoking |
cigars completely, how old |
were you when you stopped? |
Age stopped __________________ |
Check if still smoking |
cigars _______________________ |
Does not apply _______________ |
C. On the average over the entire |
time you smoked cigars, how |
many cigars did you smoke per |
week? |
Cigars per week ______________ |
Does not apply _______________ |
D. How many cigars are you |
smoking per week now? |
Cigars per week ______________ |
Check if not smoking cigars |
currently ____________________ |
E. Do or did you inhale the |
cigar smoke? |
1. Never smoked ______________ |
2. Not at all ________________ |
3. Slightly __________________ |
4. Moderately ________________ |
5. Deeply ____________________ |
Signature _________________________ Date ______________________ |
1. NAME______________________________________________________ |
2. SOCIAL | |||||||||
SECURITY# | |||||||||
_____ | _____ | _____ | _____ | _____ | _____ | _____ | _____ | _____ | |
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | |
3. CLOCK | |||||||||
NUMBER | |||||||||
_____ | _____ | _____ | _____ | _____ | _____ | ||||
10 | 11 | 12 | 13 | 14 | 15 |
4. PRESENT OCCUPATION________________________________________ |
5. PLANT_____________________________________________________ |
6. ADDRESS___________________________________________________ |
7. __________________________________________________________ |
(Zip Code) |
8. TELEPHONE NUMBER__________________________________________ |
9. INTERVIEWER_______________________________________________ |
10. DATE | ||||||
____________ | _____ | _____ | _____ | _____ | _____ | _____ |
16 | 17 | 18 | 19 | 20 | 21 |
11. What is your marital status? |
1. Single ______________________ |
2. Married _____________________ |
3. Widowed _____________________ |
4. Separated/Divorced __________ |
12. OCCUPATIONAL HISTORY |
12A. In the past year, did you work |
full time (30 hours per week or |
more) for 6 months or more? |
1. Yes _________________________ |
2. No __________________________ |
IF YES TO 12A: |
12B. In the past year, did you work |
in a dusty job? |
1. Yes _________________________ |
2. No __________________________ |
3. Does not apply ______________ |
12C. Was dust exposure: |
1. Mild ________________________ |
2. Moderate ____________________ |
3. Severe ______________________ |
12D. In the past year, were you |
exposed to gas or chemical fumes |
in your work? |
1. Yes _________________________ |
2. No __________________________ |
12E. Was exposure: |
1. Mild ________________________ |
2. Moderate ____________________ |
3. Severe ______________________ |
12F. In the past year, what was your: |
1. Job/occupation?______________ |
_____________________________ |
2. Position/job title? _________ |
____________________________ |
13. RECENT MEDICAL HISTORY |
13A. Do you consider yourself to be |
in good health? |
Yes_____________________________ |
No _____________________________ |
IF NO, state reason ____________ |
________________________________ |
________________________________ |
________________________________ |
13B. In the past year, have you | ||
developed: | Yes | No |
Epilepsy? | ______ | ______ |
Rheumatic fever? | ______ | ______ |
Kidney disease? | ______ | ______ |
Bladder disease? | ______ | ______ |
Diabetes? | ______ | ______ |
Jaundice? | ______ | ______ |
Cancer? | ______ | ______ |
14. 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) |
1. Yes ________________________ |
2. No _________________________ |
3. Don't get colds ____________ |
15A. During the past year, have you |
had any chest illnesses that |
have kept you off work, |
indoors at home, or in bed? |
1. Yes ________________________ |
2. No _________________________ |
3. Does not apply _____________ |
IF YES TO 15A: |
15B. Did you produce phlegm with any |
of these chest illnesses? |
1. Yes ________________________ |
2. No _________________________ |
3. Does Not Apply _____________ |
15C. In the past year, how many such |
illnesses with (increased) |
phlegm did you have which |
lasted a week or more? |
Number of illnesses ___________ |
No such illnesses _____________ |
16. RESPIRATORY SYSTEM | |
In the past year have you had: | Yes or No |
Asthma | _________ |
Bronchitis | _________ |
Hay Fever | _________ |
Other Allergies | _________ |
Further Comment on Positive | |
Answers ___________________ | |
___________________________ | |
Yes or No | |
Pneumonia | _________ |
Tuberculosis | _________ |
Chest Surgery | _________ |
Other Lung Problems | _________ |
Heart Disease | _________ |
Further Comment on Positive | |
Answers ___________________ | |
___________________________ | |
Do you have: | Yes or No |
Frequent colds | _________ |
Chronic cough | _________ |
Shortness of breath when | |
walking or climbing one | |
flight of stairs | _________ |
Further Comment on Positive | |
Answers ___________________ | |
___________________________ | |
Do you: | |
Wheeze | _________ |
Cough up phlegm | _________ |
Smoke cigarettes | _________ |
Packs per day ______ | |
How many years _____ | |
Date ______________________ | Signature ______________________ |
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