Asbestos health surveillance forms - Queensland Government

f. Asthma Yes No
g. Other chest trouble Yes No
h. Hay fever Yes No
Tobacco smoking
21. Do you smoke? Yes No
If No to Q21:
22. Have you ever smoked as much as one cigarette a day for as long as one year?
Yes No
If No to Q21 or Q22, omit remaining questions on smoking.
23. How old were you when you started smoking regularly? _________________
24a. Do (did) you smoke manufactured cigarettes? Yes No
If Yes to Q24a:
How many do you (did) you usually smoke per day?
Q24b. on weekdays?
Q24c. at weekends?
_________________
_________________
_________________
25. Do you smoke any other forms of tobacco? Yes No
If Yes to Q25, record details under Additional Notes
For ex-smokers:
26. When did you give up smoking altogether? Month _______Year _______
Additional notes:
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Workplace Health and Safety Queensland, Department of Justice and Attorney-General
Asbestos - health monitoring forms
PN 10445 Version 2. Last updated June 2012.