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S-2.1, r. 7 - Regulation respecting pulmonary health examinations for mine workers
Schedule
Disposition versions
SCHEDULE I
(ss. 6, 8 and 10)
MEDICAL EXAMINATIONS
IMEDICAL QUESTIONNAIRE
Social insurance number _______________________________
Name ____________________________________________
Address ___________________________________________
___________________________________________
___________________________________________
Postal code
Telephone number __________________________________
Interviewer ________________________________________
Date _____________________________________________
DEMOGRAPHIC INFORMATION
i. Date of birth __________ __________ __________
year month date
ii. Sex 1. male _____
2. female _____
iii Race 1. white ________________
2. black ________________
3. oriental ________________
4. amerindian ________________
5. other (specify) ________________
iv. Name and address of employer
__________________________________________________
__________________________________________________
__________________________________________________
v. Occupation
__________________________________________________
__________________________________________________
RESPIRATORY DISORDERS
The following questions are mainly about your lungs. Please answer “yes” or “no” whenever possible. If you hesitate between “yes” and “no”, answer “no”.
1. COUGHING
A. Do you usually have a cough? Include a cough with a first cigarette or when first going outdoors. Do not include clearing your throat.
1. yes _______ 2. no _______
If you answered no, go to question C.
B. Do you usually cough at least 4 to 6 times a day for 4 or more days per week?
1. yes _______ 2. no _______
C. Do you usually cough when getting up or waking up in the morning?
1. yes _______ 2. no _______
D. Do you usually cough during the rest of the day or at night?
1. yes _______ 2. no _______
If you answered yes to at least one of questions 1A, B, C or D, answer the questions below.
If you answered no, go to question 2A.
E. Do you cough in this manner most of the time for at least 3 consecutive months every year?
1. yes _______ 2. no _______
F. For how many years have you coughed in this manner?
Number of years ____________
2. PHLEGM
A. Do you usually cough up phlegm from your lungs? Include phlegm coughed up when smoking a first cigarette of the day or when first going outdoors. Do not include phlegm from the nose. Include phlegm that is swallowed.
1. yes _______ 2. no _______
If you answered “no”, go to question C.
B. Do you usually cough up phlegm from your lungs at least twice a day for 4 or more days per week?
1. yes _______ 2. no _______
C. Do you usually cough up phlegm from your lungs when getting up or waking up in the morning?
1. yes _______ 2. no _______
D. Do you usually cough up phlegm from your lungs during the rest of the day or at night?
1. yes _______ 2. no _______
If you answered yes to at least one of questions 2A, B, C or D, answer the following questions. If you answered no, go to question 3A.
E. Do you cough up phlegm in this manner most of the time for at least 3 consecutive months each year?
1. yes _______ 2. no _______
F. For how long have you coughed up phlegm in this manner?
Number of years ____________
3. PERIODS OF COUGHING WITH PHLEGM
A. Have you had periods of coughing with increased* phlegm lasting for 3 or more weeks each year?
* for persons who usually have a cough or cough up phlegm from their lungs.
1. yes _______ 2. no _______
If you answered “yes” to question 3A
B. For how many years have you had such periods of coughing?
Number of years ____________
4. WHISTLING OR WHEEZING SOUND IN LUNGS
Do you sometimes hear a whistling or wheezing sound in your lungs?
A. When you have a cold?
1. yes _______ 2. no _______
B. Sometimes, even when you don’t have a cold?
1. yes _______ 2. no _______
C. Most of the time?
1. yes _______ 2. no _______
If you answered yes to question 4A, B or C
D. For how long have you had this condition?
Number of years ____________
5. A. Have you ever had an attack of wheezing that left you short of breath?
1. yes _______ 2. no _______
If you answered “yes” to question 5A
B. How old were you when you had the first attack?
Age______
C. Have you had more than one attack?
1. yes _______ 2. no _______
D. Have you ever needed medication or treatment for this(these) attack(s)?
1. yes _______ 2. no _______
6. SHORTNESS OF BREATH
If you suffer from an illness, other than a heart or lung disease, that prevents you from walking normally, describe that illness.
Nature of illness:
__________________________________________________
__________________________________________________
A. Do you become short of breath even when walking on level ground or when walking slightly uphill?
1. yes _______ 2. no _______
If you answered yes to question 6A
B. Do you have to walk more slowly than people of your age on level ground because you become short of breath?
1. yes _______ 2. no _______
C. Do you ever have to stop to catch your breath when walking at your own pace on level ground?
1. yes _______ 2. no _______
D. Do you ever have to stop to catch your breath after walking about 100 m (or for a few minutes) on level ground?
E. Are you too short of breath to leave the house or do you become short of breath when getting dressed or undressed?
1. yes _______ 2. no _______
F. For how many years have you become short of breath in this manner?
Number of years ____________
7. CHEST COLDS AND LUNG DISEASES
A. When you have a cold, is it usually a chest cold? (Here, “usually” means more than half the time)
1. yes ____ 2. no ____ 3. I never have a cold ____
B. In the past 3 years, have you had a lung disease that has kept you off work or forced you to stay home or in bed?
1. yes _______ 2. no _______
If you answered yes to question 7B
C. Did you cough up phlegm from your lungs when you had any of these lung diseases?
1. yes _______ 2. no _______
D. In the past 3 years, how many of these diseases, with increased phlegm, have lasted a week or longer?
Number of diseases __________ No diseases__________
MEDICAL HISTORY
8. Did you have a lung disease before the age of 16?
1. yes _______ 2. no _______
9. A. Have you ever had acute bronchitis?
1. yes _______ 2. no _______
If you answered yes to question 9A
B. Was the disease diagnosed by a physician?
1. yes _______ 2. no _______
C. At what age did you first suffer from it?
Age______
10. A. Have you ever had pneumonia? (Include bronchopneumonia)
1. yes _______ 2. no _______
If you answered yes to question 10A
B. Was the disease diagnosed by a physician?
1. yes _______ 2. no _______
C. At what age did you first suffer from it?
Age______
11. A. Have you ever had hay fever?
1. yes _______ 2. no _______
If you answered yes to question 11A
B. Was the allergy diagnosed by a physician?
1. yes _______ 2. no _______
C. At what age did you first suffer from it?
Age______
12. A. Have you ever had chronic bronchitis?
1. yes _______ 2. no _______
If you answered yes to question 12A
B. Do you still have it?
1. yes _______ 2. no _______
C. Was the disease diagnosed by a physician?
1. yes _______ 2. no _______
D. At what age did you first suffer from it?
Age______
13. A. Have you ever had emphysema?
1. yes _______ 2. no _______
If you answered yes to question 13A
B. Do you still have it?
1. yes _______ 2. no _______
C. Was the disease diagnosed by a physician?
1. yes _______ 2. no _______
D. At what age did you first suffer from it?
Age______
14. A. Have you ever had asthma?
1. yes _______ 2. no _______
If you answered yes to question 14A
B. Do you still have it?
1. yes _______ 2. no _______
C. Was the disease diagnosed by a physician?
1. yes _______ 2. no _______
D. At what age did you begin to suffer from it?
Age______
E. If you no longer have it, at what age did it go away?
Age______
F. Do you currently require treatment or medication for asthma?
1. yes _______ 2. no _______
15. A. Have you ever had pulmonary tuberculosis?
1. yes _______ 2. no _______
If you answered yes to question 15A
B. Was the disease diagnosed by a physician?
1. yes _______ 2. no _______
C. At what age did you first suffer from it?
Age______
D. What kind of treatment did you have?
1. none __________
2. medication __________
3. an operation __________
4. other (specify) __________
E. How long did the treatment last?
1. Number of months ____________
16. A. Have you ever had pleurisy?
1. yes _______ 2. no _______
If you answered yes to question 16A
B. Was the disease diagnosed by a physician?
1. yes _______ 2. no _______
C. At what age did you first suffer from it?
Age______
17. A. Have you ever had sinus problems?
1. yes _______ 2. no _______
If you answered yes to question 17A
B. Were the problems diagnosed by a physician?
1. yes _______ 2. no _______
C. At what age did you first suffer from it?
Age______
18. Have you ever had
A. Other lung diseases?
1. yes _______ 2. no _______
If yes, specify _______________________________________
__________________________________________________
At what age _______
B. A chest or lung operation?
1. yes _______ 2. no _______
If yes, specify _______________________________________
__________________________________________________
At what age? ______
C. Chest injuries?
1. yes _______ 2. no _______
If yes, specify _______________________________________
__________________________________________________
At what age? ______
19. A. Has a physician ever diagnosed you with heart problems?
1. yes _______ 2. no _______
If you answered yes to question 19A
B. Have you been treated for heart problems in the past 10 years?
1. yes _______ 2. no _______
If yes, specify _______________________________________
__________________________________________________
20. A. Has a physician ever diagnosed you with high blood pressure?
1. yes _______ 2. no _______
If you answered yes to question 20A
B. Have you been treated for high school pressure in the past 10 years?
1. yes _______ 2. no _______
TOBACCO CONSUMPTION
21. CIGARETTES
A. Have you ever smoked cigarettes? “No” means fewer than 20 packs of cigarettes or less than 400 g of tobacco in your lifetime, or less than 1 cigarette per day for a year.
1. yes _______ 2. no _______
If you answered yes to question 21A
B. Do you currently smoke cigarettes or have you smoked cigarettes in the past month
1. yes _______ 2. no _______
C. How old were you when you started smoking cigarettes regularly?
Age______
D. If you stopped smoking cigarettes completely, at what age did you stop?
Age______
Tick here if you still smoke ____________________________
E. How many cigarettes do you currently smoke per day?
Number of cigarettes _______
F. When you smoked cigarettes, how many cigarettes did you smoke on average per day?
Number of cigarettes _______
G. Do you or did you inhale the smoke?
1. not at all ________
2. a little ________
3. moderately ________
4. deeply ________
H. Did you smoke filter-tipped cigarettes?
0. never ________
1. less than half the time ________
2. half the time ________
3. more than half the time ________
4. always ________
I. When you smoked, what kind of cigarettes did you smoke most of the time?
1. regular ________
2. king size ________
3. hand rolled ________
22. PIPE
A. Have you ever smoked a pipe regularly? “Yes” means more than 400 g or 8 pouches of tobacco in your lifetime
1. yes _______ 2. no _______
If you answered yes to question 22A
B. Do you currently smoke a pipe or have you smoked a pipe in the past month?
1. yes _______ 2. no _______
C. How old were you when you started smoking a pipe regularly?
Age______
D. If you stopped smoking a pipe completely, how old were you stopped?
Age _______ Tick here if you still smoke a pipe _______
E. How many grams of tobacco do you currently smoke per week?
_______ grams per week (a pouch contains 50 g of tobacco)
F. When you smoke a pipe, how much tobacco did you smoke on average per week?
_______ grams per week (a pouch contains 50 g of tobacco)
G. Do you or did you inhale the smoke?
1. not at all ________
2. a little ________
3. moderately ________
4. deeply ________
23. CIGARS/CIGARILLOS
A. Have you ever smoked cigars or cigarillos regularly? “Yes” means more than one cigar or cigarillo per week for a year.
1. yes _______ 2. no _______
If you answered yes to question 23A
B. Do you currently smoke cigars or have you smoked cigars in the past month?
1. yes _______ 2. no _______
C. How old were you when you began to smoke cigars regularly?
Age______
D. If you stopped smoking cigars completely, how old were you when you stopped?
Age _______ Tick here if you still smoke cigars _______
E. How many cigars do you currently smoke per week?
Number of cigars _______
F. When you smoked cigars, how many did you smoke on average per week?
Number of cigars _______
G. Do you or did you inhale the smoke?
1. not at all ________
2. a little ________
3. moderately ________
4. deeply ________
H. What kind of cigars did you smoke most of the time?
1. mini (cigarette length) ________
2. small (cigarillo) ________
3. large (real cigar) ________
FAMILY HISTORY
24. Has a member of your family been diagnosed with a chronic lung disease?
Brother
Father Mother or sister
1. yes 1. yes 1. yes
2. no 2. no 2. no
3. don’t 3. don’t 3. don’t
know know know
A. Chronic
bronchitis _____ _____ _____
B. Emphysema _____ _____ _____
C. Asthma _____ _____ _____
D. Lung
cancer _____ _____ _____
E. Tuberculosis _____ _____ _____
F. Other
respiratory
diseases _____ _____ _____
G. Eczema or
hives _____ _____ _____
H. Hay fever _____ _____ _____
25. Are you parents still living?
Father Mother
1. yes ___ 1. yes ___
2. no ___ 2. no ___
3. don’t know ___ 3. don’t know ___
26. If your parents are deceased, please specify the cause of their death.
Father ___________________________________________
Mother ___________________________________________
27. Please specify your parents’ current age or, if they are decreased, the age at which they died.
Father’s age _______
Mother’s age _______
WORKPLACE
28. A. Have you ever worked full time? (at least 30 hours a week for at least 6 months)
1. yes _______ 2. no _______
If you answered yes to question 28A
B. Have you ever worked in a dusty place for 1 year or longer?
1. yes _______ 2. no _______
Specify the type of work and the type of industry
__________________________________________________
__________________________________________________
Number of years of work _______
Was the exposure to dust
1. light ________ 2. moderate ________ 3. grave ________
C. Have you ever been exposed to gases or chemical fumes in your workplace?
1. yes _______ 2. no _______
Specify the type of work and the type of industry
__________________________________________________
__________________________________________________
Number of years of work _______
Was the exposure
1. light ________ 2. moderate ________ 3. grave ________
D. What is the occupation that you carried on for the longest time?
1. Occupation ______________________________________
2. Number of years of work ___________________________
3. Position and/or job title _____________________________
4. Field or industry work ______________________________
E. What is your current or most recent job?
1. Occupation ______________________________________
2. Number of years of work ___________________________
3. Position and/or job title _____________________________
4. Field or industry work ______________________________
5. Do you still carry on this occupation? ___________________
1. no _______
2. yes, full time _______
3. yes, part time _______
6. If you no longer carry on this occupation, how old were you when you left it? _____________________________________
29. When was the last time you had a cold or the flu?
1. I currently have a cold or the flu _____________________
2. 1 to 2 weeks ago _____________________
3. 3 to 4 weeks ago _____________________
4. 5 to 6 weeks ago _____________________
5. More than 6 weeks ago _____________________
IIPHYSICAL EXAMINATION
1. Determination of weight and size.
2. Determination of blood pressure and pulse.
3. Physical examination of the heart including an auscultation oriented specifically towards the detection of arrhythmia, murmurs and abnormal sounds.
4. Physical examination of the lungs, including an auscultation oriented towards determining the quality of the vesicular murmur and the presence of sonorous rhonchus or rales.
IIILUNG X-RAY
1. The radiological facility required for digital lung x-rays must comply with the technical standards recommended by the National Institute for Occupational Safety and Health relating to the acquisition, reading, transfer and archiving of images so that the quality of the images and their interpretation are helpful for pneumoconiosis screening.
2. For the interpretation of a digital lung x-ray, the standard digital images from the International Labour Office and the Guidelines for the use of the ILO International Classification of Radiographs of Pneumoconioses must be used.
SCHEDULE I
(ss. 6, 8 and 10)
MEDICAL EXAMINATIONS
IMEDICAL QUESTIONNAIRE
Social insurance number _______________________________
Name ____________________________________________
Address ___________________________________________
___________________________________________
___________________________________________
Postal code
Telephone number __________________________________
Interviewer ________________________________________
Date _____________________________________________
DEMOGRAPHIC INFORMATION
i. Date of birth __________ __________ __________
year month date
ii. Sex 1. male _____
2. female _____
iii Race 1. white ________________
2. black ________________
3. oriental ________________
4. amerindian ________________
5. other (specify) ________________
iv. Name and address of employer
__________________________________________________
__________________________________________________
__________________________________________________
v. Occupation
__________________________________________________
__________________________________________________
RESPIRATORY DISORDERS
The following questions are mainly about your lungs. Please answer “yes” or “no” whenever possible. If you hesitate between “yes” and “no”, answer “no”.
1. COUGHING
A. Do you usually have a cough? Include a cough with a first cigarette or when first going outdoors. Do not include clearing your throat.
1. yes _______ 2. no _______
If you answered no, go to question C.
B. Do you usually cough at least 4 to 6 times a day for 4 or more days per week?
1. yes _______ 2. no _______
C. Do you usually cough when getting up or waking up in the morning?
1. yes _______ 2. no _______
D. Do you usually cough during the rest of the day or at night?
1. yes _______ 2. no _______
If you answered yes to at least one of questions 1A, B, C or D, answer the questions below.
If you answered no, go to question 2A.
E. Do you cough in this manner most of the time for at least 3 consecutive months every year?
1. yes _______ 2. no _______
F. For how many years have you coughed in this manner?
Number of years ____________
2. PHLEGM
A. Do you usually cough up phlegm from your lungs? Include phlegm coughed up when smoking a first cigarette of the day or when first going outdoors. Do not include phlegm from the nose. Include phlegm that is swallowed.
1. yes _______ 2. no _______
If you answered “no”, go to question C.
B. Do you usually cough up phlegm from your lungs at least twice a day for 4 or more days per week?
1. yes _______ 2. no _______
C. Do you usually cough up phlegm from your lungs when getting up or waking up in the morning?
1. yes _______ 2. no _______
D. Do you usually cough up phlegm from your lungs during the rest of the day or at night?
1. yes _______ 2. no _______
If you answered yes to at least one of questions 2A, B, C or D, answer the following questions. If you answered no, go to question 3A.
E. Do you cough up phlegm in this manner most of the time for at least 3 consecutive months each year?
1. yes _______ 2. no _______
F. For how long have you coughed up phlegm in this manner?
Number of years ____________
3. PERIODS OF COUGHING WITH PHLEGM
A. Have you had periods of coughing with increased* phlegm lasting for 3 or more weeks each year?
* for persons who usually have a cough or cough up phlegm from their lungs.
1. yes _______ 2. no _______
If you answered “yes” to question 3A
B. For how many years have you had such periods of coughing?
Number of years ____________
4. WHISTLING OR WHEEZING SOUND IN LUNGS
Do you sometimes hear a whistling or wheezing sound in your lungs?
A. When you have a cold?
1. yes _______ 2. no _______
B. Sometimes, even when you don’t have a cold?
1. yes _______ 2. no _______
C. Most of the time?
1. yes _______ 2. no _______
If you answered yes to question 4A, B or C
D. For how long have you had this condition?
Number of years ____________
5. A. Have you ever had an attack of wheezing that left you short of breath?
1. yes _______ 2. no _______
If you answered “yes” to question 5A
B. How old were you when you had the first attack?
Age______
C. Have you had more than one attack?
1. yes _______ 2. no _______
D. Have you ever needed medication or treatment for this(these) attack(s)?
1. yes _______ 2. no _______
6. SHORTNESS OF BREATH
If you suffer from an illness, other than a heart or lung disease, that prevents you from walking normally, describe that illness.
Nature of illness:
__________________________________________________
__________________________________________________
A. Do you become short of breath even when walking on level ground or when walking slightly uphill?
1. yes _______ 2. no _______
If you answered yes to question 6A
B. Do you have to walk more slowly than people of your age on level ground because you become short of breath?
1. yes _______ 2. no _______
C. Do you ever have to stop to catch your breath when walking at your own pace on level ground?
1. yes _______ 2. no _______
D. Do you ever have to stop to catch your breath after walking about 100 m (or for a few minutes) on level ground?
E. Are you too short of breath to leave the house or do you become short of breath when getting dressed or undressed?
1. yes _______ 2. no _______
F. For how many years have you become short of breath in this manner?
Number of years ____________
7. CHEST COLDS AND LUNG DISEASES
A. When you have a cold, is it usually a chest cold? (Here, “usually” means more than half the time)
1. yes ____ 2. no ____ 3. I never have a cold ____
B. In the past 3 years, have you had a lung disease that has kept you off work or forced you to stay home or in bed?
1. yes _______ 2. no _______
If you answered yes to question 7B
C. Did you cough up phlegm from your lungs when you had any of these lung diseases?
1. yes _______ 2. no _______
D. In the past 3 years, how many of these diseases, with increased phlegm, have lasted a week or longer?
Number of diseases __________ No diseases__________
MEDICAL HISTORY
8. Did you have a lung disease before the age of 16?
1. yes _______ 2. no _______
9. A. Have you ever had acute bronchitis?
1. yes _______ 2. no _______
If you answered yes to question 9A
B. Was the disease diagnosed by a physician?
1. yes _______ 2. no _______
C. At what age did you first suffer from it?
Age______
10. A. Have you ever had pneumonia? (Include bronchopneumonia)
1. yes _______ 2. no _______
If you answered yes to question 10A
B. Was the disease diagnosed by a physician?
1. yes _______ 2. no _______
C. At what age did you first suffer from it?
Age______
11. A. Have you ever had hay fever?
1. yes _______ 2. no _______
If you answered yes to question 11A
B. Was the allergy diagnosed by a physician?
1. yes _______ 2. no _______
C. At what age did you first suffer from it?
Age______
12. A. Have you ever had chronic bronchitis?
1. yes _______ 2. no _______
If you answered yes to question 12A
B. Do you still have it?
1. yes _______ 2. no _______
C. Was the disease diagnosed by a physician?
1. yes _______ 2. no _______
D. At what age did you first suffer from it?
Age______
13. A. Have you ever had emphysema?
1. yes _______ 2. no _______
If you answered yes to question 13A
B. Do you still have it?
1. yes _______ 2. no _______
C. Was the disease diagnosed by a physician?
1. yes _______ 2. no _______
D. At what age did you first suffer from it?
Age______
14. A. Have you ever had asthma?
1. yes _______ 2. no _______
If you answered yes to question 14A
B. Do you still have it?
1. yes _______ 2. no _______
C. Was the disease diagnosed by a physician?
1. yes _______ 2. no _______
D. At what age did you begin to suffer from it?
Age______
E. If you no longer have it, at what age did it go away?
Age______
F. Do you currently require treatment or medication for asthma?
1. yes _______ 2. no _______
15. A. Have you ever had pulmonary tuberculosis?
1. yes _______ 2. no _______
If you answered yes to question 15A
B. Was the disease diagnosed by a physician?
1. yes _______ 2. no _______
C. At what age did you first suffer from it?
Age______
D. What kind of treatment did you have?
1. none __________
2. medication __________
3. an operation __________
4. other (specify) __________
E. How long did the treatment last?
1. Number of months ____________
16. A. Have you ever had pleurisy?
1. yes _______ 2. no _______
If you answered yes to question 16A
B. Was the disease diagnosed by a physician?
1. yes _______ 2. no _______
C. At what age did you first suffer from it?
Age______
17. A. Have you ever had sinus problems?
1. yes _______ 2. no _______
If you answered yes to question 17A
B. Were the problems diagnosed by a physician?
1. yes _______ 2. no _______
C. At what age did you first suffer from it?
Age______
18. Have you ever had
A. Other lung diseases?
1. yes _______ 2. no _______
If yes, specify _______________________________________
__________________________________________________
At what age _______
B. A chest or lung operation?
1. yes _______ 2. no _______
If yes, specify _______________________________________
__________________________________________________
At what age? ______
C. Chest injuries?
1. yes _______ 2. no _______
If yes, specify _______________________________________
__________________________________________________
At what age? ______
19. A. Has a physician ever diagnosed you with heart problems?
1. yes _______ 2. no _______
If you answered yes to question 19A
B. Have you been treated for heart problems in the past 10 years?
1. yes _______ 2. no _______
If yes, specify _______________________________________
__________________________________________________
20. A. Has a physician ever diagnosed you with high blood pressure?
1. yes _______ 2. no _______
If you answered yes to question 20A
B. Have you been treated for high school pressure in the past 10 years?
1. yes _______ 2. no _______
TOBACCO CONSUMPTION
21. CIGARETTES
A. Have you ever smoked cigarettes? “No” means fewer than 20 packs of cigarettes or less than 400 g of tobacco in your lifetime, or less than 1 cigarette per day for a year.
1. yes _______ 2. no _______
If you answered yes to question 21A
B. Do you currently smoke cigarettes or have you smoked cigarettes in the past month
1. yes _______ 2. no _______
C. How old were you when you started smoking cigarettes regularly?
Age______
D. If you stopped smoking cigarettes completely, at what age did you stop?
Age______
Tick here if you still smoke ____________________________
E. How many cigarettes do you currently smoke per day?
Number of cigarettes _______
F. When you smoked cigarettes, how many cigarettes did you smoke on average per day?
Number of cigarettes _______
G. Do you or did you inhale the smoke?
1. not at all ________
2. a little ________
3. moderately ________
4. deeply ________
H. Did you smoke filter-tipped cigarettes?
0. never ________
1. less than half the time ________
2. half the time ________
3. more than half the time ________
4. always ________
I. When you smoked, what kind of cigarettes did you smoke most of the time?
1. regular ________
2. king size ________
3. hand rolled ________
22. PIPE
A. Have you ever smoked a pipe regularly? “Yes” means more than 400 g or 8 pouches of tobacco in your lifetime
1. yes _______ 2. no _______
If you answered yes to question 22A
B. Do you currently smoke a pipe or have you smoked a pipe in the past month?
1. yes _______ 2. no _______
C. How old were you when you started smoking a pipe regularly?
Age______
D. If you stopped smoking a pipe completely, how old were you stopped?
Age _______ Tick here if you still smoke a pipe _______
E. How many grams of tobacco do you currently smoke per week?
_______ grams per week (a pouch contains 50 g of tobacco)
F. When you smoke a pipe, how much tobacco did you smoke on average per week?
_______ grams per week (a pouch contains 50 g of tobacco)
G. Do you or did you inhale the smoke?
1. not at all ________
2. a little ________
3. moderately ________
4. deeply ________
23. CIGARS/CIGARILLOS
A. Have you ever smoked cigars or cigarillos regularly? “Yes” means more than one cigar or cigarillo per week for a year.
1. yes _______ 2. no _______
If you answered yes to question 23A
B. Do you currently smoke cigars or have you smoked cigars in the past month?
1. yes _______ 2. no _______
C. How old were you when you began to smoke cigars regularly?
Age______
D. If you stopped smoking cigars completely, how old were you when you stopped?
Age _______ Tick here if you still smoke cigars _______
E. How many cigars do you currently smoke per week?
Number of cigars _______
F. When you smoked cigars, how many did you smoke on average per week?
Number of cigars _______
G. Do you or did you inhale the smoke?
1. not at all ________
2. a little ________
3. moderately ________
4. deeply ________
H. What kind of cigars did you smoke most of the time?
1. mini (cigarette length) ________
2. small (cigarillo) ________
3. large (real cigar) ________
FAMILY HISTORY
24. Has a member of your family been diagnosed with a chronic lung disease?
Brother
Father Mother or sister
1. yes 1. yes 1. yes
2. no 2. no 2. no
3. don’t 3. don’t 3. don’t
know know know
A. Chronic
bronchitis _____ _____ _____
B. Emphysema _____ _____ _____
C. Asthma _____ _____ _____
D. Lung
cancer _____ _____ _____
E. Tuberculosis _____ _____ _____
F. Other
respiratory
diseases _____ _____ _____
G. Eczema or
hives _____ _____ _____
H. Hay fever _____ _____ _____
25. Are you parents still living?
Father Mother
1. yes ___ 1. yes ___
2. no ___ 2. no ___
3. don’t know ___ 3. don’t know ___
26. If your parents are deceased, please specify the cause of their death.
Father ___________________________________________
Mother ___________________________________________
27. Please specify your parents’ current age or, if they are decreased, the age at which they died.
Father’s age _______
Mother’s age _______
WORKPLACE
28. A. Have you ever worked full time? (at least 30 hours a week for at least 6 months)
1. yes _______ 2. no _______
If you answered yes to question 28A
B. Have you ever worked in a dusty place for 1 year or longer?
1. yes _______ 2. no _______
Specify the type of work and the type of industry
__________________________________________________
__________________________________________________
Number of years of work _______
Was the exposure to dust
1. light ________ 2. moderate ________ 3. grave ________
C. Have you ever been exposed to gases or chemical fumes in your workplace?
1. yes _______ 2. no _______
Specify the type of work and the type of industry
__________________________________________________
__________________________________________________
Number of years of work _______
Was the exposure
1. light ________ 2. moderate ________ 3. grave ________
D. What is the occupation that you carried on for the longest time?
1. Occupation ______________________________________
2. Number of years of work ___________________________
3. Position and/or job title _____________________________
4. Field or industry work ______________________________
E. What is your current or most recent job?
1. Occupation ______________________________________
2. Number of years of work ___________________________
3. Position and/or job title _____________________________
4. Field or industry work ______________________________
5. Do you still carry on this occupation? ___________________
1. no _______
2. yes, full time _______
3. yes, part time _______
6. If you no longer carry on this occupation, how old were you when you left it? _____________________________________
29. When was the last time you had a cold or the flu?
1. I currently have a cold or the flu _____________________
2. 1 to 2 weeks ago _____________________
3. 3 to 4 weeks ago _____________________
4. 5 to 6 weeks ago _____________________
5. More than 6 weeks ago _____________________
IIPHYSICAL EXAMINATION
1. Determination of weight and size.
2. Determination of blood pressure and pulse.
3. Physical examination of the heart including an auscultation oriented specifically towards the detection of arrhythmia, murmurs and abnormal sounds.
4. Physical examination of the lungs, including an auscultation oriented towards determining the quality of the vesicular murmur and the presence of sonorous rhonchus or rales.
IIILUNG X-RAY
1. A lung x-ray shall be a post-anterior projection of the lungs on 355 mm by 432 mm x-ray film.
2. The x-ray equipment shall conform to the characteristics relating to the high kilovoltage technique described in Appendix A of Guidelines for the Use of ILO International Classification of Radiographs of Pneumoconiosis, as amended, published by the International Labour Office in 1980.
3. The examination procedure and the interpretation of a lung x-ray shall conform to Appendix A of the guidelines referred to in paragraph 2.
4. A standard set of films from the International Labour Office shall always be used in the interpretation of a lung x-ray.
