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B. OCCUPATIONAL HISTORY TABLE

Complete the following table showing the entire work history of the individual from present to initial employment. Sporadic, part-time periods of employment, each of no significant duration, should be grouped if possible.

C. SYMPTOMS

Use actual wording of each question. Put X in appropriate square after each question. When in doubt record "No".

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19. In the past, has your chest ever been tight or 10 Yes your breathing difficult on any particular day of

2 No

the week?

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Years

38. Cigarettes

(<5) (5-9)|(10-14) | (15-19)|(20-24)|(25-29) (30-34) (35-39) (>40)

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