Are you currently exposed to any of the following?
no
yes
dust or fibers
no
yes
chemicals
no
yes
fumes
no
yes
radiation
no
yes
biologic agents
no
yes
loud noise, vibration, extreme heat or cold
no
yes
2.
Have you been exposed to any of the above in the past?
no
yes
3.
Do any household members have contact with
metals, dust, fibers, chemicals, fumes, radiation, or biologic agents?
no
yes
If you answered yes to any of the items above, describe your exposure in detail -- how you were exposed, to what you were exposed. If you need more space, please use a separate sheet of paper.
4.
Do you know the names of the metals, dusts, fibers, chemicals, fumes, or radiation that you are/were exposed to?
no
yes
5.
Do you get the material on your skin or clothing?
no
yes
6.
Are your work clothes laundered at home?
no
yes
7.
Do you shower at work?
no
yes
8.
Can you smell the chemical or material you are working with?
no
yes
9.
Do you use protective equipment such as gloves, masks, respirator, or hearing protectors?
no
yes
10.
Have you been advised to use protective equipment?
no
yes
11.
Have you been instructed in the use of protective equipment?
no
yes
If yes to question 4, list them below
If yes to question 9, list the protective equipment used
12.
Do you wash your hands with solvents?
no
yes
13.
Do you smoke at the workplace?
no
yes
At home?
no
yes
14.
Are you exposed to secondhand tobacco smoke at the workplace?
no
yes
At home?
no
yes
15.
Do you eat at the workplace?
no
yes
16.
Do you know of any co-workers experiencing similar or unusual symptoms?
no
yes
17.
Are family members experiencing similar or unusual symptoms?
no
yes
18.
Has there been a change in the health or behavior of family pets?
no
yes
19.
Do your symptoms seem to be aggravated by a specific activity?
no
yes
20.
Do your symptoms get either worse or better at work?
no
yes
at home?
no
yes
on weekends?
no
yes
on vacation?
no
yes
21.
Has anything about your job changed in recent months
(such as duties, procedures, overtime)?
no
yes
22.
Do you use any traditional or alternative medicines?
no
yes
If you answered yes to any of the questions, please explain.
Name: ___________________________
Birth date: __________________
Sex: Male Female
The following questions refer to your current or most recent job:
Job title: ______________________
Describe this job: _____________________________
Type of industry: ________________
Name of employer: ______________
Date job began: ________________
Are you still working in this job? yes no
If no, when did this job end? ______
Fill in the table below listing all jobs you have worked including short-term, seasonal, part-time employment, and military service. Begin with your most recent job. Use additional paper if necessary.
*List the chemicals, dusts, fibers, fumes, radiation, biologic agents (i.e., molds or viruses) and physical agents (i.e., extreme heat, cold, vibration, or noise) that you were exposed to at this job.
Have you ever worked at a job or hobby in which you came in contact with any of the following by breathing, touching, or ingesting (swallowing)? If yes, please check the circle beside the name.
