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QUESTIONNAIRE FOR DETECTING SKIN AND LUNG PROBLEMS

Birth Sex: M or F (please
circle)
SURNAME: Mohammadu niijam Date of Birth: 22/03/1999
Male

FORENAME(S): Inshap mohammed OCCUPATION: Graduate composites engineer

Potential Hazards at work: (e.g. name chemicals/substances or species of animal you
COMPANY NAME:Prodrive composites ltd work with.)

DESCRIPTION OF JOB:
(Where exactly do you work in workplace?) Composite machining and trimming
Exposure in previous employment?
Length of time in this job: 9 hrs

Please complete the following questionnaire carefully answering all of the questions, giving details as requested.
Since your last review or in the past 12 months: answer Yes, No or N/A (which means Not Applicable).

LUNG PROBLEMS: YES NO Please give full details including dates, treatments, etc.
1 Do you cough first thing in the morning in winter? yes
Do you usually cough during the day or night in the
2 yes
winter?
IF YOUR ANSWERS ARE “NO” TO THE ABOVE, GO YES NO
DIRECTLY TO QUESTION NUMBER 6
3 Do you cough like this on most days for as much as three no
months each year?
4 Do you bring up phlegm from your chest first thing in the no
morning in the winter?
5 Do you bring up phlegm from your chest during the day or no
night in winter?
6 In the past year, have you had a chest illness that has kept no
you from your usual activities for as much as one week? Nose bleeding with blood during winter time or when i am getting fizzy
7 Have you had any attack of wheezing or shortness of no drinks
breath? If “YES” please say at what time of day or night.
8 Have you been woken at night by an attack of shortness of no
breath?
9 Was your breathing absolutely normal between attacks?
(Only answer if applicable.)
10 Are you troubled by shortness of breath when hurrying on no
level ground or walking up a slight hill?
11 Have you developed tightness or breathlessness on yes
exercise?
12 Have you had any itching of your eyes? no
13 Have you developed any sneezing attacks? no
14 Have you had any blocking or running of your nose? yes
Do you think your LUNG symptoms are work related? If Detail possible causes at work.
15 no
“YES” please give details of why you feel this is the case.
16 Do you think your EYE symptoms are work related? If no
“YES” please give details of why you feel this is the case.
17 Do you think your NOSE symptoms are work related? If no
“YES” please give details of why you feel this is the case.
18 Do you smoke now? If “YES” state how many per day. no

19 Are you an ex-smoker? If “YES” give date you stopped no

and for how long you smoked.
Have you ever in your life suffered from any of the
20 YES NO Please give full details including dates, etc.
following:
a Heart trouble or disease? no
b Bronchitis? no
c Pneumonia? no
d Pleurisy? no
e Tuberculosis? no
© MK Occupational Health Limited 2011 - Form 703.1
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f Asthma? no
g Hay fever? no
h Injury or operation affecting the chest? no
i Any other chest trouble? no
21 Do you use respiratory protective equipment at work, e.g. yes
mask, respirator or sealed airflow helmet? Give details.

© MK Occupational Health Limited 2011 - Form 703.1

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Answer all of the questions. Tick Yes or No boxes or circle N/A

SKIN PROBLEMS: YES NO Please give full details including dates, etc.
22 Have you ever had acne? no
23 Do you have warts? no
24 Do you suffer from Psoriasis? no
25 Do you suffer from eczema? no
26 Do you suffer from any other skin disease or ailment? no
27 Do you suffer from allergy to any of the following: YES NO
a Cosmetics or toiletries? no
b Pills, potions, tablets or drugs? no

c Any chemical or substance you are exposed to no

at work?
d Any chemical or substance you are in contact no
with at home?
e Any animals, animal fur or feathers? no
f Grass or tree pollens? no
g Food allergy, e.g. to peanuts? (name foods) no
h Any other allergen? (give details) no

28 Since your last review or in the last 12 months, have you YES NO
had any of the following symptoms:
a Redness or swelling of fingers or hands? no
b Cracking of skin on fingers or hands? no
c Blisters on fingers or hands? no
d Flaking or scaling of skin on fingers or hands? no

e Itching of fingers or hands with skin cracks or no

splits?
f Spots, redness, swelling or rash on any other n/a
parts of the body? (Give full details) or N/A
g Did these problems last for more than 3 weeks? n/a or N/A
h Did these problems occur more than once? n/a or N/A
i Does the skin get better with periods off work? n/a
Have you lost time from work with skin problems
j n/a
since your last assessment or in the last year? or N/A
k Do you think you know what causes the skin n/a
problem?
Do you think that your SKIN problem is related
l to your work? If “YES” please explain in detail n/a
why you think this is so.
m Name the substance/material/contact you think n/a
is responsible.
29 Do you apply any ointments or creams to your skin no
prescribed by a doctor or specialist?
30 Do you use protective clothing at work, e.g. gloves, yes
impervious clothing, etc.? (Specify exactly what you use.)
31 Do you use barrier creams at work? (Specify make of no
cream and whether you use it regularly or occasionally.)
32 Do you use emollient creams after work? (Give details of no
creams you use.)
33 Do you use special skin cleansers or degreaser to clean no
your hands after work? (Please give details and names.)
34 Do any of your blood relatives suffer from asthma, hay no
fever or eczema? (Please give exact details.)
Have you had any sick leave in the past 12 months, other toothache from half broken front teeth and blood bleeding from
35 yes
than that already mentioned above? (Give details.) nose/Fever
Do you wish to mention anything else concerning your
36 health, which may have a relevance to your work? (Please
give details.)

The information on this form will remain confidential to the occupational health department where record is filed.
Thank you for completing this form so carefully and for giving exact details. Please sign and date below.

© MK Occupational Health Limited 2011 - Form 703.1

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Please check that you have completed all of the questions and given full details in the spaces provided. Please ask the nurse or doctor if
you do not understand a question.

Signed: ……Inshap Mohammed…………………………………………………Date: …11/02/2024…………………………………

© MK Occupational Health Limited 2011 - Form 703.1