Application for free silicosis screening

  The items marked with an asterisk are necessary for us to complete your evaluation.
* First Name:
* Last Name:
Address:
Address 2:
City:
State:
ZIP:
Telephone: () -
* E-mail Address:
  If you are inquiring on behalf of another person, please give their name and answer the following questions on their behalf:
Name of person:
Date of Birth / /
* Are you currently having any breathing problems? Yes No
Did your exposure to silica occur through work? Yes No
If Yes:
     What was your occupation? 1. 2. 3.
     What company(ies) were you working for? 1. 2. 3.
     Where are the companies located?
    City State
1.
2.
3.
If No:
     How do you believe you were exposed?
     Where did the exposure occur?
City State
 
When did your exposure first occur? Years Ago
How long were you exposed for? Years
 
Have you ever had lung X-rays taken? Yes No
     If Yes, what was the reason?
 
Have you ever been diagnosed with asbestosis or an other asbestos-related disease? Yes No
 
Are you, or were you ever, a smoker? Yes No
If Yes:
     How long? Years
     How Many packs/day? packs/day
 
Would you like to make any other comments about your case?
 
 

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