When Started:
__ last 24 hours
__ last 2-3 days
__ last week
__ > 1 month
__ > 3 months
__ other _____________________ |
Contact with Allergens/Irritants:
__ poison ivy/oak/
poison sumac
__ pollen
__ mold
__ water/moisture
__ plant(s) ___________________
__ other _____________________ |
Where pt was when injured/became ill:
__ on farm
__ away from farm
__ living quarters
__ work site
__ other |
Type of Injury/Illness :
__ strain/sprain
__ contusion
__ skin related
__ internal infection/ illness
__ other |
Exposure to Chemicals:
__ pesticides
__ cleaning agents
__ fertilizers
__ fuels/solvents/vapors_________
__________________________
__ other _____________________ |
Who talked to?
__ boss/supervisor
__ co-worker(s)
__ spouse/partner
__ relatives
__ friends
__ no one
__ other ___________ |
Cause of Injury/Illness:
__ bitten/stung (by) ______________
__ caught in Machinery___________
__ crushed (by) _________________
__ cut (by) _____________________
__ burned (by) __________________
__ fell (from) ___________________
__ pierced (by)__________________
__ rubbed (by) __________________
__ struck (by):
__ tree branch______________
__equipment_______________
__ vehicle ________________
__ tool ___________________
__ bucket/bin ______________
__ other __________________
__ sexual contact ________________
__ other _______________________ |
How exposure/contact occurred
__ eyes
__ mouth/hand to mouth
__ skin
__ breathing
__ other _____________________ |
Others experiencing same symptoms?
__ spouse/partner
__ children
__ friends
__ co-workers
__ boss/supervisor
__ other ___________ |