RUTLAND STATE SANATORIUM 
N a me 
2 (a) 
Case No. 
OCCUPATION 
I. 
Industry 
Work done 
How long 
I’resent 
Previous 
Name and address of present or last employer 
II. Description of Work Done by Patient, including 
(а) Material handled 
(б) Working hours 
(c) General description of actual work. (It is not necessary to repeat in detail work done at well known processes such as 
cotton weaving or spinning, shoe lasting or other processes described in works on occupational hygiene but the actual 
process chould be named and any unusual work done should be described as fully as possible) 
111. Working Conditions 
Extreme heat 
cold 
moisture 
Is it necessary to pass from one extreme of heat to another 
Dust 
of what kind 
Irritating fumes of acids or chemicals 
YVliat kind 
Exposure to poisonous metals or chemicals either as solids 
liquids 
or fumes 
Physical strain due to 
(a) Muscular effort at work 
(1) Local 
(2) General 
(6) Strained position at work 
(c) General nervous strain 
General physical 
(rf) Constant sitting 
(e) Anything else such as speed of work, etc. 
IV. Anything not enumerated bearing on the development of this case in relation to occupation