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Questionnaire

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The deadline for online questionnaire submissions for employees being tested at our mobile units is a week prior to the start of the job. Be aware that we cannot access any forms after the deadline on the mobile units and paper copies will need to be completed.
Alliance Health Resources Mobile Division Ltd. | 2910 Center St
Deer Park, TX | 77536 | 281.479.6672

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The following form is for office personnel and account setup purposes. It is not intended to be a means to contact Alliance Health Resources for emergency medical needs. If your matter is urgent, please call 911.

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This field is for validation purposes and should be left unchanged.
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
SS#*
Company*
Employee ID
Email*

Your results may be sent to you by email. Please provide an email for which you can receive your results.
Medical History
Indicate if you have ever had any of the following medical conditions:*
- Anemia / Bleeding Disorders / Blood Disease
- Skin Rash or Chronic Sores
- Chronic cough / Sneezing / Unusual shortness of breath
- Chronic nose bleeds
- Skin cancer
- Nasal ulcerations or perforations
- Chronic sinus problems
- None of the above
Social History
Have you ever smoked tobacco regularly?*
- No
- Yes
Check the smoking types that apply:*
- Cigarettes
- Pipe
- Cigars
Packs per day?*
Pipes per day?*
Cigars per day?*
Do you smoke now?*
- No
- Yes
Do you or have you participated in the following hobbies?*
- Woodworking/Metalwork
- Chrome plating
- Welding/soldering
- None of the above
Occupational History
Have you ever been exposed to hexavalent chromium?*
- No
- Yes
Have you ever worn a respirator for protection against hexavalent chromium?*
- No
- Yes
Have you ever worn personal protection equipment on current or previous jobs for chemical exposure?*
- No
- Yes
If yes, please explain:*
Have you ever had a chest x-ray?*
- No
- Yes
If yes, when was last chest x-ray?*
Check any previous occupations you have had.*
- Industrial Chromium Production
- Electro/Plating Industry
- Metal Industry
- Graphic Trade
- Textile/Fur Industry
- Insulator
- Foundry Work
- Furniture Industry
- Mechanical/Machinist
- Lumber/Paper Work
- Shipyard Worker
- Sandblaster
- Degreaser
- Printer
- Miner
- None of the above
Check any previous exposures.*
- Beryllium
- Welding Fumes
- Rubber/Plastics
- Noise
- Mercury
- Asbestos
- Sulfur Dioxide
- Radiation
- Gases/Fumes
- Lead
- Benzine
- Other Dust
- Silica
- Chlorine Bases
- Arsenic
- Talc
- Other Irritant
- Fluoride
- Caustics (acids and bases)
- Pesticides or Related Chemicals
- Other Metals
- Repeated Physical Trauma
- Other Oils/Machining Fluid
- Other Solvents
- Other Man-Made Fibers (Wool)
- None of the above
Employee Signature*

Alliance Health Resources Mobile Division Ltd.

2910 Center St

Deer Park, TX

77536

281.479.6672

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