1. During the past 12 months, that is, since (12 month date) a year ago, have you had --
a. Repeated trouble with neck, back or spine?
1[] Yes -- Specify ____
2[] No
b. A condition affecting the wrist and hand, called carpal tunnel syndrome?
1[] Yes
2[] No
c. A condition affecting the fingers and/or toes, called Raynaud's (R?' n?des) phenomenon?
1[] Yes
2[] No
d. A condition affecting the tendons called tendonitis?
1[] Yes
2[] No
During the past 12 months have you had --
e. Hepatitis?
1[] Yes
2[] No
f. Skin cancer?
1[] Yes
2[] No
g. Lung cancer?
1[] Yes
2[] No
h. Asthma?
1[] Yes
2[] No
i. Chronic bronchitis?
1[] Yes
2[] No
j. Emphysema?
1[] Yes
2[] No
k. Any dust disease of the lungs, such as silicosis, asbestosis, brown lung, or black lung disease?
1[] Yes -- Specify ____
2[] No
2. Do you now have --
a. Deafness in one or both ears?
1[] Yes
2[] No
b. Any other trouble hearing in one or both ears?
1[] Yes
2[] No