DD Form 2493-1 Asbestos Exposure Part I - Initial Medical Questionnaire

DD Form dd2493-1 - also known as the "Asbestos Exposure Part I - Initial Medical Questionnaire" - is a United States Military form issued by the Department of Defense.

The form - often incorrectly referred to as the DA form dd2493-1 - was last revised on January 1, 2000. Download an up-to-date fillable PDF version of the DD dd2493-1 below or request a copy through the chain of command.

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ASBESTOS EXPOSURE
PART I - INITIAL MEDICAL QUESTIONNAIRE
IDENTIFICATION
1. NAME
2. SOCIAL SECURITY NO.
3. CLOCK NO.
4. PRESENT OCCUPATION
(Last, First, Middle Initial)
(1 - 9)
(10 - 15)
5. NAME OF PLANT
6. STREET ADDRESS OF PLANT
7. PLANT CITY, STATE AND ZIP CODE
8. TELEPHONE NO.
9. NAME OF INTERVIEWER
10. DATE OF INTERVIEW
11. DATE OF BIRTH
12. PLACE OF BIRTH
(Include area code)
(16 - 21) (YYYYMMDD)
(22 - 29) (YYYYMMDD)
16. HIGHEST GRADE
13. SEX
14. MARITAL STATUS
15. RACE (X one)
(X one)
(X one)
COMPLETED IN
a. MALE
a. SINGLE
b. MARRIED
a. WHITE
b. BLACK
c. ASIAN
SCHOOL
b. FEMALE
c. WIDOWED
d. DIVORCED/SEPARATED
d. HISPANIC
e. INDIAN
f. OTHER
MEDICAL DATA
17. OCCUPATIONAL HISTORY
Yes
No
N/A
Yes
No
N/A
21. DID YOU HAVE ANY LUNG TROUBLE BEFORE THE AGE
OF 16?
a. HAVE YOU EVER WORKED FULL TIME (30 hours per week or more)
FOR SIX MONTHS OR MORE?
22. HAVE YOU EVER HAD ANY OF THE FOLLOWING?
b. IF YES, HAVE YOU EVER WORKED FOR A YEAR OR MORE IN ANY
DUSTY JOB? *If Yes, complete (1) - (3).
a. ATTACKS OF BRONCHITIS * If yes, complete (1) and (2).
(2) Total
(1) Specify Job/Industry
(3) Dust Exposure (X one)
(1) Age at first attack
(2) Was it confirmed by a doctor?
years
worked
b. ATTACKS OF PNEUMONIA (Include bronchopneumonia)
MILD
*If yes, complete (1) and (2)
MODERATE
(1) Age at first attack
(2) Was it confirmed by a doctor?
SEVERE
c. HAVE YOU EVER BEEN EXPOSED TO GAS OR CHEMICAL
c. HAY FEVER * If yes, complete (1) and (2).
FUMES IN YOUR WORK? *If Yes, complete (1) - (3).
(1) Age at first attack
(2) Was it confirmed by a doctor?
(2) Total
(1) Specify Job/ Industry
(3) Exposure (X one)
years
23. HAVE YOU EVER HAD CHRONIC BRONCHITIS?
worked
MILD
a. IF YES, DO YOU STILL HAVE IT?
MODERATE
b. WAS IT CONFIRMED BY A DOCTOR?
SEVERE
d. WHAT HAS BEEN YOUR USUAL OCCUPATION - THE ONE YOU HAVE WORKED AT
c. AT WHAT AGE DID IT START? (List age)
THE LONGEST?
24. HAVE YOU EVER HAD EMPHYSEMA?
(2) Number of years employed in this
(1) Job/Occupation
occupation
a. IF YES, DO YOU STILL HAVE IT?
b. WAS IT CONFIRMED BY A DOCTOR?
(3) Position/Job Title
(4) Business, Field or Industry
c. AT WHAT AGE DID IT START? (List age)
25. HAVE YOU EVER HAD ASTHMA?
e. HAVE YOU EVER WORKED (X Yes or No
Years Worked
and specify years worked, e.g. 1960 - 1969.)
a. IF YES, DO YOU STILL HAVE IT?
(1) In a mine
b. WAS IT CONFIRMED BY A DOCTOR?
(2) In a quarry
c. AT WHAT AGE DID IT START? (List age)
(3) In a foundry
d. IF YOU NO LONGER HAVE IT, AT WHAT AGE DID IT STOP? (List age)
(4) In a pottery
26. HAVE YOU EVER HAD:
(5) In a cotton, flax or hemp mill
a. ANY OTHER CHEST ILLNESSES *If yes, please specify.
(6) With asbestos
18. MEDICAL HISTORY
a. DO YOU CONSIDER YOURSELF TO BE IN GOOD HEALTH? *If No,
b. ANY CHEST OPERATIONS *If yes, please specify.
state reason.
b. HAVE YOU ANY DEFECT OF VISION? *If Yes, state nature of
c. ANY CHEST INJURIES *If yes, please specify.
defect.
c. HAVE YOU ANY HEARING DEFECT? *If Yes, state nature of
27. HEART TROUBLE
defect.
a. HAS A DOCTOR EVER TOLD YOU THAT YOU HAD HEART TROUBLE?
d. ARE YOU SUFFERING FROM OR HAVE YOU EVER SUFFERED FROM
b. IF YES, HAVE YOU EVER HAD TREATMENT FOR HEART TROUBLE IN
(1) Epilepsy (Or fits, seizures or convulsions)
THE PAST TEN YEARS?
(2) Rheumatic Fever
28. HIGH BLOOD PRESSURE
(3) Kidney Disease
a. HAS A DOCTOR EVER TOLD YOU THAT YOU HAD HIGH BLOOD
(4) Bladder Disease
PRESSURE (Hypertension)?
(5) Diabetes
b. IF YES, HAVE YOU EVER HAD TREATMENT FOR HIGH BLOOD
PRESSURE IN THE PAST TEN YEARS?
(6) Jaundice
*
19. IF YOU GET A COLD, DOES IT USUALLY GO TO YOUR
29. WHEN DID YOU LAST HAVE YOUR CHEST X-RAYED?
(Year)
CHEST?
(Usually means more than 1/2 of the time)*Don't get colds
20. CHEST ILLNESSES
30. CHEST X-RAY
a. DURING THE PAST THREE YEARS, HAVE YOU HAD ANY
CHEST
a. WHERE DID YOU LAST HAVE YOUR CHEST X-RAYED? (If known)
ILLNESSES THAT HAVE KEPT YOU OFF WORK, INDOORS AT HOME,
OR IN BED?
b. IF YES, DID YOU PRODUCE PHLEGM WITH ANY OF THESE
b WHAT WAS THE OUTCOME?
ILLNESSES?
c. IN THE LAST THREE YEARS, HOW MANY SUCH ILLNESSES WITH INCREASED PHLEGM
DID YOU HAVE WHICH LASTED A WEEK OR MORE? (List number)
DD FORM 2493-1, JAN 2000
PREVIOUS EDITION MAY BE USED.
Reset
Adobe Professional 7.0
ASBESTOS EXPOSURE
PART I - INITIAL MEDICAL QUESTIONNAIRE
IDENTIFICATION
1. NAME
2. SOCIAL SECURITY NO.
3. CLOCK NO.
4. PRESENT OCCUPATION
(Last, First, Middle Initial)
(1 - 9)
(10 - 15)
5. NAME OF PLANT
6. STREET ADDRESS OF PLANT
7. PLANT CITY, STATE AND ZIP CODE
8. TELEPHONE NO.
9. NAME OF INTERVIEWER
10. DATE OF INTERVIEW
11. DATE OF BIRTH
12. PLACE OF BIRTH
(Include area code)
(16 - 21) (YYYYMMDD)
(22 - 29) (YYYYMMDD)
16. HIGHEST GRADE
13. SEX
14. MARITAL STATUS
15. RACE (X one)
(X one)
(X one)
COMPLETED IN
a. MALE
a. SINGLE
b. MARRIED
a. WHITE
b. BLACK
c. ASIAN
SCHOOL
b. FEMALE
c. WIDOWED
d. DIVORCED/SEPARATED
d. HISPANIC
e. INDIAN
f. OTHER
MEDICAL DATA
17. OCCUPATIONAL HISTORY
Yes
No
N/A
Yes
No
N/A
21. DID YOU HAVE ANY LUNG TROUBLE BEFORE THE AGE
OF 16?
a. HAVE YOU EVER WORKED FULL TIME (30 hours per week or more)
FOR SIX MONTHS OR MORE?
22. HAVE YOU EVER HAD ANY OF THE FOLLOWING?
b. IF YES, HAVE YOU EVER WORKED FOR A YEAR OR MORE IN ANY
DUSTY JOB? *If Yes, complete (1) - (3).
a. ATTACKS OF BRONCHITIS * If yes, complete (1) and (2).
(2) Total
(1) Specify Job/Industry
(3) Dust Exposure (X one)
(1) Age at first attack
(2) Was it confirmed by a doctor?
years
worked
b. ATTACKS OF PNEUMONIA (Include bronchopneumonia)
MILD
*If yes, complete (1) and (2)
MODERATE
(1) Age at first attack
(2) Was it confirmed by a doctor?
SEVERE
c. HAVE YOU EVER BEEN EXPOSED TO GAS OR CHEMICAL
c. HAY FEVER * If yes, complete (1) and (2).
FUMES IN YOUR WORK? *If Yes, complete (1) - (3).
(1) Age at first attack
(2) Was it confirmed by a doctor?
(2) Total
(1) Specify Job/ Industry
(3) Exposure (X one)
years
23. HAVE YOU EVER HAD CHRONIC BRONCHITIS?
worked
MILD
a. IF YES, DO YOU STILL HAVE IT?
MODERATE
b. WAS IT CONFIRMED BY A DOCTOR?
SEVERE
d. WHAT HAS BEEN YOUR USUAL OCCUPATION - THE ONE YOU HAVE WORKED AT
c. AT WHAT AGE DID IT START? (List age)
THE LONGEST?
24. HAVE YOU EVER HAD EMPHYSEMA?
(2) Number of years employed in this
(1) Job/Occupation
occupation
a. IF YES, DO YOU STILL HAVE IT?
b. WAS IT CONFIRMED BY A DOCTOR?
(3) Position/Job Title
(4) Business, Field or Industry
c. AT WHAT AGE DID IT START? (List age)
25. HAVE YOU EVER HAD ASTHMA?
e. HAVE YOU EVER WORKED (X Yes or No
Years Worked
and specify years worked, e.g. 1960 - 1969.)
a. IF YES, DO YOU STILL HAVE IT?
(1) In a mine
b. WAS IT CONFIRMED BY A DOCTOR?
(2) In a quarry
c. AT WHAT AGE DID IT START? (List age)
(3) In a foundry
d. IF YOU NO LONGER HAVE IT, AT WHAT AGE DID IT STOP? (List age)
(4) In a pottery
26. HAVE YOU EVER HAD:
(5) In a cotton, flax or hemp mill
a. ANY OTHER CHEST ILLNESSES *If yes, please specify.
(6) With asbestos
18. MEDICAL HISTORY
a. DO YOU CONSIDER YOURSELF TO BE IN GOOD HEALTH? *If No,
b. ANY CHEST OPERATIONS *If yes, please specify.
state reason.
b. HAVE YOU ANY DEFECT OF VISION? *If Yes, state nature of
c. ANY CHEST INJURIES *If yes, please specify.
defect.
c. HAVE YOU ANY HEARING DEFECT? *If Yes, state nature of
27. HEART TROUBLE
defect.
a. HAS A DOCTOR EVER TOLD YOU THAT YOU HAD HEART TROUBLE?
d. ARE YOU SUFFERING FROM OR HAVE YOU EVER SUFFERED FROM
b. IF YES, HAVE YOU EVER HAD TREATMENT FOR HEART TROUBLE IN
(1) Epilepsy (Or fits, seizures or convulsions)
THE PAST TEN YEARS?
(2) Rheumatic Fever
28. HIGH BLOOD PRESSURE
(3) Kidney Disease
a. HAS A DOCTOR EVER TOLD YOU THAT YOU HAD HIGH BLOOD
(4) Bladder Disease
PRESSURE (Hypertension)?
(5) Diabetes
b. IF YES, HAVE YOU EVER HAD TREATMENT FOR HIGH BLOOD
PRESSURE IN THE PAST TEN YEARS?
(6) Jaundice
*
19. IF YOU GET A COLD, DOES IT USUALLY GO TO YOUR
29. WHEN DID YOU LAST HAVE YOUR CHEST X-RAYED?
(Year)
CHEST?
(Usually means more than 1/2 of the time)*Don't get colds
20. CHEST ILLNESSES
30. CHEST X-RAY
a. DURING THE PAST THREE YEARS, HAVE YOU HAD ANY
CHEST
a. WHERE DID YOU LAST HAVE YOUR CHEST X-RAYED? (If known)
ILLNESSES THAT HAVE KEPT YOU OFF WORK, INDOORS AT HOME,
OR IN BED?
b. IF YES, DID YOU PRODUCE PHLEGM WITH ANY OF THESE
b WHAT WAS THE OUTCOME?
ILLNESSES?
c. IN THE LAST THREE YEARS, HOW MANY SUCH ILLNESSES WITH INCREASED PHLEGM
DID YOU HAVE WHICH LASTED A WEEK OR MORE? (List number)
DD FORM 2493-1, JAN 2000
PREVIOUS EDITION MAY BE USED.
Reset
Adobe Professional 7.0
ASBESTOS EXPOSURE
PART I - INITIAL MEDICAL QUESTIONNAIRE
MEDICAL DATA
(Continued)
38. BREATHLESSNESS
31. WERE EITHER OF YOUR NATURAL
Father
Mother
Yes
No
N/A
PARENTS TOLD THAT THEY HAD A
Don't
Don't
a. ARE YOU TROUBLED BY SHORTNESS OF BREATH WHEN HURRYING
Yes
No
Yes
No
CHRONIC LUNG CONDITION SUCH AS
Know
Know
ON THE LEVEL OR WALKING UP A SLIGHT
HILL?
b. IF YES, DO YOU HAVE TO WALK SLOWER THAN PEOPLE OF YOUR
a. CHRONIC BRONCHITIS
AGE ON THE LEVEL BECAUSE OF BREATHLESSNESS?
b. EMPHYSEMA
c. DO YOU EVER HAVE TO STOP FOR BREATH WHEN WALKING AT
YOUR OWN PACE ON THE LEVEL?
c. ASTHMA
d. DO YOU EVER HAVE TO STOP FOR BREATH AFTER WALKING
d. LUNG CANCER
ABOUT 100 YARDS (or after a few minutes) ON THE LEVEL?
e. OTHER CHEST CONDITIONS
e. ARE YOU TOO BREATHLESS TO LEAVE THE HOUSE OR BREATH-
f. IS PARENT CURRENTLY ALIVE?
LESS ON DRESSING OR CLIMBING ONE FLIGHT OF STAIRS?
g. Please specify
39. CIGARETTE SMOKING
AGE IF LIVING
*
a. HAVE YOU EVER SMOKED CIGARETTES? *No means less
AGE AT DEATH
than 20 packs of cigarettes or 12 oz. of tobacco in a lifetime or
N/A
N/A
Father:
Mother:
CAUSE OF DEATH
less than 1 cigarette a day for 1 year.
32. COUGH
b. IF YES, DO YOU NOW SMOKE CIGARETTES? (As of one
month ago)?
*
a. DO YOU USUALLY HAVE A COUGH? (Count a cough with first
smoke or on first going out of doors.
Exclude clearing of throat.)
c. HOW OLD WERE YOU WHEN YOU FIRST STARTED REGULAR
*If No, skip to question 32.c.
CIGARETTE SMOKING? (Number of years)
b. DO YOU USUALLY COUGH AS MUCH AS FOUR TO SIX TIMES
A DAY FOUR OR MORE DAYS OUT OF THE WEEK?
d. IF YOU HAVE STOPPED SMOKING CIGARETTES COMPLETELY,
HOW OLD WERE YOU WHEN YOU STOPPED?
c. DO YOU USUALLY COUGH AT ALL ON GETTING UP OR FIRST
(List age in (1) or X (2))
THING IN THE MORNING?
(1) Age in years
(2) Still smoking
d. DO YOU USUALLY COUGH AT ALL DURING THE REST
OF THE DAY OR AT NIGHT?
e. HOW MANY CIGARETTES DO YOU SMOKE PER DAY NOW?
IF YES TO ANY OF ABOVE (32.a., b., c., or d.), ANSWER THE
FOLLOWING. IF NO TO ALL, X "N/A" AND SKIP TO ITEM 33.
f. ON THE AVERAGE OF THE ENTIRE TIME YOU SMOKED,
e. DO YOU USUALLY COUGH LIKE THIS ON MOST DAYS
FOR
HOW MANY CIGARETTES DID YOU SMOKE PER DAY?
THREE CONSECUTIVE MONTHS OR MORE DURING THE YEAR?
f. FOR HOW MANY YEARS HAVE YOU HAD THE COUGH?
g. DO OR DID YOU INHALE CIGARETTE SMOKE (X one)
33. PHLEGM
(1) Not at all
(2) Slightly
(3) Moderately
(4) Deeply
*
a. DO YOU USUALLY BRING UP PHLEGM FROM YOUR CHEST?
(Count phlegm with the first smoke or on first going out of doors.
40. PIPE SMOKING
Exclude phlegm from the nose. Count swallowed phlegm.)
*
*If No, skip to Item 33.c.
a. HAVE YOU EVER SMOKED A PIPE REGULARLY?
b. DO YOU USUALLY BRING UP PHLEGM LIKE THIS AS
MUCH AS
*Yes means more than 12 oz. of tobacco in a lifetime.
TWICE A DAY FOUR OR MORE DAYS OUT OF THE WEEK?
b. HOW OLD WERE YOU WHEN YOU FIRST STARTED PIPE SMOKING?
c. DO YOU USUALLY BRING UP PHLEGM AT ALL ON
(Number of years)
GETTING UP OR
FIRST
THING IN THE MORNING?
d. DO YOU USUALLY BRING UP PHLEGM AT ALL DURING
c. IF YOU HAVE STOPPED SMOKING A PIPE COMPLETELY, HOW OLD
THE REST OF THE DAY OR AT NIGHT?
WERE YOU WHEN YOU STOPPED? (List age in (1) or X (2))
IF YES TO ANY OF ABOVE (33.a., b., c., or d.), ANSWER THE
FOLLOWING. IF NO TO ALL, X "N/A" AND SKIP TO ITEM 34.
(1) Age in years
(2) Still smoking
d. ON THE AVERAGE OF THE ENTIRE TIME YOU SMOKED, HOW
e. DO YOU USUALLY BRING UP PHLEGM LIKE THIS ON MOST DAYS
FOR THREE CONSECUTIVE MONTHS OR MORE DURING THE YEAR?
MUCH PIPE TOBACCO DID YOU SMOKE PER WEEK?
(Oz. per week - a standard pouch of tobacco contains 1 1-1/2 oz.)
f. FOR HOW MANY YEARS HAVE YOU HAD TROUBLE WITH PHLEGM?
34. EPISODES OF COUGH AND PHLEGM
e. HOW MUCH PIPE TOBACCO DO YOU SMOKE PER WEEK NOW?
a. HAVE YOU HAD PERIODS OR EPISODES OF (increased*) COUGH
AND PHLEGM LASTING FOR THREE WEEKS OR MORE EACH YEAR?
*For persons who usually have cough and/or phlegm
f. DO OR DID YOU INHALE PIPE SMOKE (X one)
b. FOR HOW LONG HAVE YOU HAD AT LEAST ONE SUCH
EPISODE PER YEAR? (Number of years)
(1) Not at all
(2) Slightly
(3) Moderately
(4) Deeply
35. WHEEZING/WHISTLING
41. CIGAR SMOKING
*
a. DOES YOUR CHEST EVER SOUND WHEEZY OR WHISTLING
a. HAVE YOU EVER SMOKED CIGARS REGULARLY?
*Yes means more than 1 cigar a week for a year.
(1) When you have a cold
b. HOW OLD WERE YOU WHEN YOU FIRST STARTED REGULAR CIGAR
(2) Occasionally apart from colds
SMOKING? (Number of years)
(3) Most days or nights
b. IF YES TO 35.a.(1), (2) or (3), FOR HOW MANY YEARS
c. IF YOU HAVE STOPPED SMOKING CIGARS COMPLETELY, HOW OLD
HAS THIS BEEN PRESENT (Number of years)
WERE YOU WHEN YOU STOPPED? (List age in (1) or X (2))
36. WHEEZING/SHORTNESS
OF BREATH
(1) Age in years
(2) Still smoking
a. HAVE YOU EVER HAD AN ATTACK OF WHEEZING THAT HAS
d. ON THE AVERAGE OF THE ENTIRE TIME YOU SMOKED, HOW MANY
MADE YOU FEEL SHORT OF BREATH?
CIGARS DID YOU SMOKE PER WEEK?
b. IF YES, HOW OLD WERE YOU WHEN YOU HAD YOUR FIRST SUCH
ATTACK? (Number of years)
e. HOW MANY CIGARS DO YOU SMOKE PER WEEK NOW?
c. HAVE YOU HAD TWO OR MORE SUCH EPISODES?
d. HAVE YOU EVER REQUIRED MEDICINE OR TREATMENT FOR THE(SE)
ATTACKS?
f. DO OR DID YOU INHALE CIGAR SMOKE (X one)
37. IF DISABLED FROM WALKING BY ANY CONDITION OTHER THAN HEART
(1) Not at all
(2) Slightly
(3) Moderately
(4) Deeply
OR LUNG DISEASE, PLEASE DESCRIBE NATURE OF CONDITION(S) AND
43. SIGNATURE
44. DATE SIGNED
PROCEED TO QUESTION 39.a.
(YYYYMMDD)
DD FORM 2493-1 (BACK), JAN 2000
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