U.S. Department of Labor Medical History and Examination for Coal Mine Workers' Pneumoconiosis 2IILFH RI :RUNHUV &RPSHQVDWLRQ 3URJUDPV 'LYLVLRQ RI &RDO 0LQH :RUNHUV &RPSHQVDWLRQ Note: This report is authorized by law (30 USC 901 et. seq) and required to receive a benefit. The results of this interpretation will aid in determining the miner's eligibility for black lung benefits. Disclosure of a social security number is voluntary. The failure to disclose such number will not result in the denial of any right, benefit, or privilege to which the claimant may be entitled. The method of collecting information complies with the Freedom of Information Act, the Privacy Act of 1974, and OMB Cir. No. 108. (Please type all responses.) A. Patient Information 1. Name and Address 2. DOL Claim No. OMB No.:  Expires:  4. Date of Exam 3. Telephone No. 5. Date of Birth 7. Examining Physician (name, address, phone no.) 6. Personal Physician (name, address, phone no.) (Please type or neatly print all responses.) B. Employment History ) is attached. Please review the form and, with the miner's ''Employment History'', Form CM-911a, or equivalent (dated help, complete only blocks 1.a, below, describing his/her most recent coal mine job (of at least one year's duration). Then, move on to "C. Patient History'' CM-911a is not attached - complete both sections, 1. and 2., below. 1. Coal Mine Employment - CME. List most recent employment first. In line (a.) describe the last job of at least one year's duration. (Include in all lines any coal mine construction or transportation work, or work in a mine preparation facility.) Name of Company Job Title and Description of Job's Physical Requirements From To a. Last CME held at least one year. b. Other CME: years. c. Additional number of years in CME not described above: 2. Other Employment - Not CME. (If the employment exposed the patient to an occupational toxic inhalant hazard, describe the inhalant under ''Job Title and Description''.) Name of Company Job Title and Description From To (mm/yy) (mm/yy) C. Patient History (Family - Medical - Social) 1. Family History. (Please type or neatly print all responses.) Have the patient's parents, children, or other ''blood'' relatives ever had any of the following: Yes No Yes High blood pressure Heart Disease Tuberculosis If ''Yes,'' identify family member Allergies Emphysema Diabetes No Asthma Stroke Cancer Page 1 American LegalNet, Inc. www.FormsWorkFlow.com Form CM-988 Rev.Jan.1997 C. Patient History (continued) 2. Individual Health/Medical History. (Please type all responses.) a. Does the patient have a history of: Yes When Manifested No Yes No When Manifested Arthritis Frequent Colds Pneumonia Heart Disease/Problems Pleurisy Attacks of wheezing Allergies Cancer (of Tuberculosis Diabetes Mellitus Chronic bronchitis Bronchial Asthma High Blood Pressure Connective Tissue Disease ) b. Other Significant Conditions or Serious Illnesses (when diagnosed?) c. Hospitalizations (reasons and dates): d. Surgery: 3. Social History. a. Smoking History Never Smoked Has Stopped Smoking Started: Smoked what? How much: Currently Smoking Started: Smokes what? ; Stopped: 1 cigarette(s) per day How much: 1 cigarette(s) per month b. Other Pertinent Social History (e.g. drug or alcohol use; strenuous hobbies): (Please type or neatly print all responses.) D. Present Illness/Physical Examination 1. Chief Complaints/Symptoms - as described by patient. Please comment on all ''Yes'' answers (e.g. describe frequency, duration, and/or severity of symptoms). Yes No Comments Sputum (daily?) Wheezing (daily?) Dyspnea (quantitate) Cough Hemoptysis Chest pain (Inciting Factor): Orthopnea Ankle edema Paroxysmal Nocturnal Dyspnea (Indicate in D.4., next page, any of the above symptoms manifested during the exam.) 2. Other complaints. (Include here the patient's description of any limitations in physical activities like walking, climbing, and lifting.) Page 2 American LegalNet, Inc. www.FormsWorkFlow.com D. Present Illness/Physical Exam (continued) 3. Current Treatment (including medications): (Please type all responses.) 4. Physical Findings: Based on Your Physical Examination. (Show all findings, especially those pertinent to the respiratory system and the cardiovascular system.) a. Fill in the appropriate data or response: Thorax & Lungs Inspection General Nose Membranes Abdomen Peristalsis Obstruction Tenderness Weight Palpation Discharge Septum Ascites Liver Temperature Percussion Sinuses Spleen Pulse Respiration Auscultation Throat Kidneys Urinary bladder B.P. rt. arm Erythema Masses B.P. If. arm Development Hernia Heart Exudate Tonsils Nutrition Peripheral Pulse Pharynx Hydration Orientation PMI Pulsation Neck Mentation Epigastric Cardiac Pulsation Height Masses Thyroid Trachea Personality Mood Thrills Rhythm Arteries Extremities Color Sounds Gallop Veins Clubbing Murmurs Musculoskeletal Friction rub Spine Joints Edema Varicosities Arterial Pulses Muscles b. Other relevant findings - narrative summary: 5. Summary of Diagnostic Testing -in the space below, check the applicable block(s) next to any test results (including those conducted in conjunction with this physical exam) which you reviewed and relied upon, at least in part, to base your medical assessments and conclusions - especially those on the next page. Be sure to show the date(s) of each test, and summarize the results. Dates Summary of Results Chest X-ray Vent Study (PFS) Arterial Blood Gas Other: Other: Page 3 American LegalNet, Inc. www.FormsWorkFlow.com D. Present Illness/Physical Exam (Continued) 6. Cardiopulmonary Diagnosis (es): (And provide the basis (as) for your stated diagnosis (es).) (Please type all responses.) 7. Etiology of Cardiopulmonary Diagnosis (es):(List Primary and Secondary Causes - if applicable - and Provide Rationale.) 8. Impairment - If the patient has chronic respiratory or pulmonary disease, give your medical assessment - With Rationale - of: a. The degree of severity of the impairment, particularly in terms of the extent to which the impairment prevents the patient from performing his/her current or last coal mine job of one year's duration: (Refer to section B.1.a. of this form.) b. The extent to which each of the diagnoses listed in D.6. above contributes to the impairment: 9. Non-Cardiopulmonary Diagnosis -if the patient has any disabling non-respiratory condition(s) indicate what the condition is and describe its degree of impairment, especially as it may affect the patient's ability to perform his coal mine work: E. Physician Referral Should this patient be referred to another physician for further evaluation? For what reason? Y N Has referral been made? Y N F. Physician Signature I certify that the information furnished is correct and am aware that my signature attests to its accuracy. I am also aware that any person who willfully makes any false or misleading statement or representation in support of an application for benefits shall be guilty under Title 30 USC 941 of a misdemeanor and subject to a fine of up to $1,000., or to imprisonment for up to one year, or both. Signature: Date: (Physician's name should be typewritten on front page of this form.) Public Burden Statement We estimate that it will take an average of 30 minutes per response to complete this information collection, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have any comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the Division of Coal Mine Workers' Compensation, U.S. Department of Labor, Room N-3464, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE Note: Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. Page 4 American LegalNet, Inc. www.FormsWorkFlow.com