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| Environmental Medicine | CSEM | GREM | Continuing Education | Patient Education | PEHT | Community | |
Agency for Toxic Substances and Disease Registry
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| Name: ______________ | Date: ________ |
| Birth date: _______ | Sex (circle one): Male Female |
Please circle the appropriate answer.
| 1. | Are you currently exposed to any of the following? | ||
| metals | no | yes | |
| dust or fibers | no | yes | |
| chemicals | no | yes | |
| fumes | no | yes | |
| radiation | no | yes | |
| loud noise, vibration, extreme heat or cold | no | yes | |
| biologic agents | 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, to what extent (how much) you were exposed if you know. If you need more space, please use a separate sheet of paper. |
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| 4. | Do you know the names of the metals, dusts, fibers, chemicals, fumes, or radiation that you are/were exposed to? [If yes, list them below.] | 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, hearing protectors? [If yes, list the protective equipment used.] | 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 |
| 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 coworkers experiencing similar or unusual symptoms? | no | yes |
| 17. | Are family members experiencing similar or un-usual 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 |
| 23. | Have you or your child ever eaten on-food items, such as paint, plaster, dirt, clay? | no | yes |
| If you answered yes to any of the questions, please explain. | |||
| 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: ________________ |
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| Name of employer: ______________ |
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| Date job began: ________________ |
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| Are you still working in this job? yes no |
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| If no, when did this job end? ______ |
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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.
| Dates of Employment | Job Title and Description of Work | Exposures* | Protective Equipment |
|---|---|---|---|
*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. | |||||||
| Ο | Acids | Ο | Chloroprene | Ο | Methylene chloride | Ο | Styrene |
| Ο | Alcohols (industrial) | Ο | Chromates | Ο | Nickel | Ο | Talc |
| Ο | Alkalies | Ο | Coal dust | Ο | PBBs | Ο | Toluene |
| Ο | Ammonia | Ο | Dichlorobenzene | Ο | PCBs | Ο | TDI or MDI |
| Ο | Arsenic | Ο | Ethylene dibromide | Ο | Perchloroethylene | Ο | Trichloroethylene |
| Ο | Asbestos | Ο | Ethylene dichloride | Ο | Pesticides | Ο | Trinitrotoluene |
| Ο | Benzene | Ο | Fiberglass | Ο | Phenol | Ο | Vinyl chloride |
| Ο | Beryllium | Ο | Halothane | Ο | Phosgene | Ο | Welding fumes |
| Ο | Cadmium | Ο | Isocyanates | Ο | Radiation | Ο | X-rays |
| Ο | Carbon tetrachloride | Ο | Ketones | Ο | Rock dust | Ο | Other (specify) |
| Ο | Chlorinated naphthalenes | Ο | Lead | Ο | Silica powder | ||
| Ο | Chloroform | Ο | Mercury | Ο | Solvents | ||
Please circle the appropriate answer.
| 1. | Have you ever been off work for more than 1 day because of an illness related to work? | no | yes |
| 2. | Have you ever been advised to change jobs or work assignments because of any health problems or injuries? |
no | yes |
| 3. | Has your work routine changed recently? | no | yes |
| 4. | Is there poor ventilation in your workplace? | no | yes |
Please circle the appropriate answer.
| 1. | Do you live next to or near an industrial plant, commercial business, dump site, or nonresidential property? | no | yes | |||
| 2. | Which of the following do you have in your home? Please circle those that apply. |
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| Air conditioner | Air purifier | Central heating (gas or oil?) |
Gas stove | |||
| Electric stove | Fireplace | Wood | Humidifier | |||
| 3. | Have you recently acquired new furniture or carpet, refinished furniture, or remodeled your home? | no | yes | |||
| 4. | Have you weatherized your home recently? | no | yes | |||
| 5. | Are pesticides or herbicides (bug or weed killers; flea and tick sprays, collars, powders, or shampoos) used in your home or garden, or on pets? | no | yes | |||
| 6. | Do you (or any household member) have a hobby or craft? | no | yes | |||
| 7. | Do you work on your car? | no | yes | |||
| 8. | Have you ever changed your residence because of a health problem? | no | yes | |||
| 9. | Does your drinking water come from a private well, city water supply, or grocery store? | no | yes | |||
| 10. | Approximately what year was your home built?_______________ | |||||
| If you answered yes to any of the questions, please explain. |
* Developed by ATSDR in cooperation with NIOSH, 1992
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| Agency for Toxic Substances and Disease Registry 4770 Buford Hwy NE, Atlanta, GA 30341-3717 Contact CDC: 800-232-4636 / TTY: 888-232-6348 cdcinfo@cdc.gov |
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