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
*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 box beside the name.
B. Occupational Exposure InventoryPlease circle the appropriate answer.
1. Have you ever been off work for more than 1 day because of an illness related to work?
2. Have you ever been advised to change jobs or work assignments because of any health problems or injuries?
3. Has your work routine changed recently?
4. Is there poor ventilation in your workplace?
Part 3. Environmental History
Please circle the appropriate answer.
1. Do you live next to or near an industrial plant, commercial business, dump site, or nonresidential property?
2. Which of the following do you have in your home?
Please circle those that apply.
3. Have you recently acquired new furniture or carpet, refinished furniture, or remodeled your home?
4. Have you weatherized your home recently?
5. Are pesticides or herbicides used in your home or garden, or on pets?
(bug or weed killers; flea and tick sprays, collars, powders,
6. Do you (or any household member) have a hobby or craft?
7. Do you work on your car?
8. Have you ever changed your residence because of a health problem?
9. Does your drinking water come from a private well, city water supply, or grocery store?
10. Approximately what year was your home built?
If you answered yes to any of the questions, please explain.