Periodic asbestos medical questionnaire 2025

1. Click ‘Get Form’ to open the periodic asbestos medical questionnaire in the editor.
2. Begin by filling in your personal information at the top of the form, including your name, social security number, date, present occupation, company, address, and zip code.
3. Next, provide your telephone number and doctor's name. Indicate your marital status by selecting one of the options: Single, Separated, Married, Divorced, or Widowed.
4. In the Occupational History section, answer whether you worked full-time for six months or more in the past year. If yes, continue to specify if you were in a dusty job and detail any exposure to gas or chemical fumes.
5. Proceed to Recent Medical History and indicate if you consider yourself in good health. If not, provide a reason. Answer questions regarding any illnesses developed in the past year.
6. Complete the Chest Colds and Chest Illness section by answering questions about colds and chest illnesses experienced over the past year.
7. Finally, review your responses for accuracy before signing and dating the form at the end.

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