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Available on

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Non-Licensed Asbestos Respiratory Questionnaire (United Kingdom) Mobile App

This mobile app covers information on occupation, respiratory symptoms, and smoking. Also included is doctor signature and insurance information.

  • Lendlease
  • The Cooperative
  • PG&E
  • oxy
  • Red Bull
  • Mirvac

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Take a peek inside the Non-Licensed Asbestos Respiratory Questionnaire (United Kingdom) Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Name of employer/business name

  • Ico multiline

    Address

  • Ico textbox

    National Insurance Number

  • Ico statictext

    and/or

  • Ico textbox

    Date of Birth

  • Ico textbox

    The medical examination was carried out on

  • Ico textbox

    Registration Number of Doctor

  • Ico statictext

    Have you ever, or since your last examination had:

  • Ico checkbox

    (a) an injury or operation affecting your chest?

  • Ico checkbox

    (b) pleurisy?

  • Ico checkbox

    (c) pulmonary tuberculosis

  • Ico checkbox

    Do you usually cough during the day (or at night when on night work)

  • Ico checkbox

    Do you usually bring up any phlegm from your chest on most days (or nights) for as much as three ...

  • Ico checkbox

    Do you usually get short of breath when walking with people of your own age on level ground?

  • Ico checkbox

    During the past three years, or since your last examination, have you had any chest illness, whic...

  • Ico checkbox

    Did you bring up more phlegm than usual in any of these illnesses?

  • Ico textbox

    How many illnesses like this have you had in the past three years or since your last examination?

  • Ico textbox

    Have you ever smoked?

  • Ico textbox

    Do you smoke at present?

  • Ico textbox

    Have you given up smoking in the last month?

  • Ico textbox

    How old were you when you started smoking regularly?

  • Ico textbox

    How many manufactured cigarettes do you usually smoke or were you smoking per day?

  • Ico textbox

    How much tobacco do you usually smoke or were you smoking per day?

  • Ico textbox

    How much pipe tobacco do you usually smoke or were you smoking per day?

  • Ico textbox

    How many small cigars do you usually smoke or were you smoking per day?

  • Ico textbox

    How many large cigars do you usually smoke or were you smoking per week?

  • Ico statictext

    Ex-Smokers only

  • Ico textbox

    How old were you when you last smoked?

  • ...and More!

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