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Subject: MEDICAL HISTORY A N D PHYSICIAN'S MEDICAL SUMMARY FORMS Attached are the 1a tes t Medi cal Hi story- and Physi ci a n ' s Medi cal Summary to participants. These appear to satisfy the. Registrfs needs for medical information i f the Medical History i s compqeted by.-the-emp-Toyee a t the time of his next periodic medical examination and the Physician's Medical Summary is completed t o indicate the medical findings a t the,time of the i n d i vi dual medi cal employment examination for transurani um work or the examination nearest before his entry on transuranium work. These may be forwarded t o the Registry by participating facilities at intervals of six t o twelve months for employees a t risk i n transuranium work. A t intervals of five years the physician would again complete the Physician's Medical Summary form and the employee would complete the Registrant Interim Medical History form BD-8800-604, also enclosed. Participants may use the longer forms or send copies of t h e i r completed histories and physicals i f they prefer. ticipants suggested t h a t this would be much simpler, cheaper and should satisfy Registry needs, and we agree. Results t o date a t Hanford, the first project t o participate, are that release forms and some 25% have signed the authorization.for autopsy Los Alamos , and t o a lesser extent, Mound, Savannah River and Oak Ridge The change was made because parOther projects now participating i n the Registry are Rocky Flats, We anticipate visiting the various licensee plants which are handling unsealed sources of transuranium elements i n the near future to solicit your participation i n the Registry. any questions. Please write or' call us i f you have rated for the U. S. Atomic Energy Commission by the Hanford Environmental Health foundation
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OPERATED FOR THE HANFORD ENVIRONMENTAL HEALTH FOUNDATION P 0. BOX 100, RICHLAND WASHINGTON 99352 SOCIAL SECURITY NUM BE RV AME II PHYSICIAN'S MEDICAL SUMMARY -Y E SF OR COMPLETION BY PHYSICIAN OR PARAMEDICAL PERSONNEL WITH PHYSICIAN REVIEW: - I. ARE THERE ANY SIGNIFICANT ABNORMALITIES OR DISEASES.PASTOR PRESENT. FOUND ON PHYSICAL EXAMINATION OR MEDICAL HISTORY7 2. ARE THERE ANY SIGNIFICANT CLINICAL LABORATORY FINDINGS ? 4. IS THERE EVIDENCE OF INTERNAL BODY OE POSITION OF RADIOACTIVE IFYES,PLEASE INDICATE HOW OE POSITION OCCURRED : BY INHALATION U VIA WOUND 1IF ANY YES ANSWERS TO THE ABOVE PLEASE EXPLAIN BELOW :
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SOCIAL SECURITY NUMBER DATE STATE ZIP COD EH OME ADDRESS CITY BIRTHDATE MARITAL STATUS NAME AND ADDRESS OF PERSONAL PHYSICIAN HAVE YOU EVER WORKED WITH OR AROUND ANY OF THE FOLLOWING ? SER YL LIU M HAZARDOUS CHEMICALS, DUSTS, METALS, SOLVENTS, GASES, ETC. HAVE YOU EVER BEEN GIVEN RADIOACTIVE AATERIALS FOR MEDICAL DIAGNOSIS OR TREATMENT7 HAVE YOU EVER RECEIVED X-RAY, COBALT OR RAO I UM TREATMENTS ’ ! I F ANSWER 15 “YES” TO ANY OF ABOVE. PLEASE EXPLAIN: 1W HAT MEDICINES.ORUGS.OR OTHER REMEDIES DO YOU OCCASIONALLY OR REGULARLY TAKE ?
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I HANFORO ENVIRONMENTAL HEALTH FOUNDATION UNITED STATES TRANSURANIUM REGISTRY P. 0 . BOX 100, RICHLAND, WASHINGTON 99352 SOCIAL SECURITY NUMBER REGISTRANT INTERIM MEDICAL HISTORY HAS ANY OF THE FOLLOWING OCCURRED SINCE LAST COMPANY EXAMINATION ? NO EXPLANATION SY E S WEIGHT GAINED OR LOST DIZZINESS OR FAINTING SPELLS SHORTNESS OF BREATH 10 1FREQUENT POOR APPETITE Ill I PERSISTENT STOMACH DISTRESS PERSISTENT O IAR RHEA URINATION FREQUENT OR PAINFUL SWELLING OF HANDS - FEET OR JOINTS 16HAY FEVER OR ASTHMA 18 1PERSISTENT FATIGUE OR WEAKNESS 19 SURGERY OR HOSPITALIZATION T H I S W I L L CERTIFY THAT I HAVE REVIEWED THE ABOVE INFORMATION AND ANSWERED THE OUESTIONS TO THE BEST OF MY KNOWLEDGE. UNR F PORTED JOB INCURRED DIAGNOSTIC OR TREATMENT CONSULTED PRIVATE PHYSICIAN