Health and Safety
Control of Asbestos Regulations 2012 - Regulation 22(3)
Questionnaire - Respiratory Symptom - Non Licensed Work
*Does your work involve working with asbestos containing materials?
*How long have you been doing this work?
Enter years and/or months
Have you ever, or since your last examination had:
• *an injury or operation affecting your chest?
• *pulmonary tuberculosis?
*Do you usually cough during the day (or at night when on night work)?
*Do you usually bring up any phlegm from your chest on most days (or
nights) for as much as three months each year?
*Do you usually get short of breath when walking with people of your
own age on level ground?
*During the past three years, or since your last examination, have you
had any chest illness which has kept you from your usual activities for
as much as a week?
Did you bring up more phlegm than usual in any of these illnesses?
How many illnesses like this have you had in the past three years
or since your last examination?
*Have you ever smoked?
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*Do you smoke at present?
*Have you given up smoking in the last month?
*How old were you when you started smoking regularly? Enter age in years
(a regular smoker is defined
as someone who has smoked one cigarette or one small cigar a day or one ounce of tobacco a month for as long as a year)
How many manufactured cigarettes do you usually smoke or were you smoking per day?
How much tobacco do you usually smoke or were you smoking per day?
How much pipe tobacco do you usually smoke or were you smoking per day?
Enter number of grams
(1 ounce = 28 grams)
How many small cigars do you usually smoke or were you smoking per day?
How many large cigars do you usually smoke or were you smoking per week?
How old were you when you last smoked? Enter age in years
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Certificate of Medical Examination - Non-Licensed Work
Address Line 1
(eg building name)
Address Line 2
Address Line 3
Date of Birth
*Registration Number of Doctor
*The medical examination was carried out on
Print/Save Form button
below, not File > Print, to open the Form Summary window for printing.
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