Initial Questionnaire

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This screen is for evaluating baseline ChE levels and health status of workers at the beginning of each spray season.

Physical Exam Findings

Vital Signs

Systolic BP The Systolic value is not in the valid limits

Diastolic BP The Diastolic value is not in the valid limits

Respiratory rate The respiratory rate value is not in the valid limits

Heart rate

The heart rate value is not in the valid limits

bpm

Temperature

The respiratory rate value is not in the valid limits

Height Inches

The height value is not in the valid limits

Inches

Weight

The weight value is not in the valid limits

lbs

BMI

History of work related injury or impairment (if yes, please specify)

Past Medical History

Diabetes

Hypertension

Irritable bowel syndrome, inflammatory bowel disorder, or chronic diarrhea

Asthma

Possible Prior Episodes of Poisoning Related to Cholinesterase Inhibitors

Acute accidental exposure

Prior removal from handling cholinesterase inhibiting insecticides

History of work related illness or injury

Drug Allergy History

Penicillin

Sulfa

Tetracycline

Fluoroquinolone

Other Medication (Please specify)

None

Head and Neck

Normal conjunctiva and EOM

Pupils midrange, reactive to light and accomodation

Neck show normal range of motion, no adenopathy, thyromegaly or jugular venous distension or carotid bruit

Exercise Capacity

Normal

Chest

No rales, wheezes or abnormal breath sounds

Normal cardiac rhythm, no murmurs, or abnormal heart sounds

Abdomen

Normal abdominal bowel sounds, no tenderness

No organomegaly, abdominal masses, or hernias

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