23.

Dust work questionnaire

Instructions
1. Employees should fill in the six items of demographic data, working experience, examination time, past
medical history, living habits and self-perceived symptoms before the workers health examination. Then it
should be submitted to the health care workers for confirmation and to screen out disease effectively. If the
working unit has provided the electronic files of demographic data and working experience of the employees
to the designated medical institutions, the employees should not be asked to fill them in repeatedly.
2. For self-perceived symptoms, the employees should check the symptoms according to their actual symptoms.
I. Demographic data
1. Name
2. Sex Male Female
3. ID card number (passport number)
4. Date of birth______Year_____Month_____Date
Date
5. Date of employment____Year___ Month
6. Date of examination
Year
Month
Date
II. Working experience
1. Had worked for
,
Since (date)____Year____Month, Until (date)____Year____Month, Total

Year (s)

Month (s)

2. Is working for
,
Since (date)____Year____Month, Until (date)____Year____Month, Total

Year (s)

Month (s)

III. Past medical history

Have you suffered from the following chronic diseases?
1. Cardiovascular system Heart diseases
None

(Please check the appropriate item)

2. Respiratory system Tuberculosis

Asthma
Pneumoconiosis
None
3. None of the above
IV. Living habitssingle choice
1. Have you smoked in the past month?
Never smoke
Smoke occasionally (not daily)
(Almost) smoke daily, average smoke
Quit smoking, quit for
year(s)

cigarette(s) daily, smoke for

month(s)

year(s)

2. Have you chewed betel nut in the past six months?

Never chew
Chew occasionally (not daily)
(Almost) chew daily, average chew
betel nut(s) daily, chew for
Quit chewing, quit for

year(s)

year(s)

month(s)

3. Have you drank alcohol in the past month?

Never drink
Drink occasionally (not daily)
(Almost) drink daily, average drink time(s) weekly, drink____most often, ___ bottle(s) each time
Quit drinking, quit for
year(s)
month(s)
V. Self-perceived symptoms (Please check the appropriate item)
Have you had the following symptoms in the last three months frequently?
1. Cardiovascular system Chest pain
Tachycardia (working, walking, resting)
Anemia
2. Respiratory system Difficulty in breathing (Remarks 1 2 3 4 5)
Cough
Expectoration
3. Others_________
4. None of the above
Remarks
Difficulty in breathing1 refers to a healthy person of the same age who can work, walk, climb uphill and go up
and down stairs.
Difficulty in breathing2 refers to a healthy person of the same age who can walk but cannot climb uphill and
go up stairs.
Difficulty in breathing3 refers to a healthy person of the same age who cannot walk on flat ground, but can
walk more than one km at his own pace.
Difficulty in breathing4 refers to a person who must stop after walking for more than 50 meters.
Difficulty in breathing5 refers to a person who has difficulty in breathing due to taking or dressing, so he
cannot walk outside his home.