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.