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Exposure History Form
Part 1. Exposure Survey
Please circle the appropriate answer.
Name
Date:
Not Set
Birth date:
Not Set
Sex
MaleFemale
1. Are you currently exposed to any of the following?
- metals
YesNo
- dust or fibers
YesNo
- chemicals
YesNo
- fumes
YesNo
- radiation
YesNo
- biologic agents
YesNo
- loud noise, vibration, extreme heat or cold
YesNo
2. Have you been exposed to any of the above in the past?
YesNo
3. Do any household members have contact with metals, dust, fibers, chemicals, fumes, radiation, or biologic agents?
YesNo
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?
YesNo
If yes, list them below
5. Do you get the material on your skin or clothing?
YesNo
6. Are your work clothes laundered at home?
YesNo
7. Do you shower at work?
YesNo
8. Can you smell the chemical or material you are working with?
YesNo
9. Do you use protective equipment such as gloves, masks, respirator, or hearing protectors?
YesNo
If yes, list the protective equipment used
10. Have you been advised to use protective equipment?
YesNo
11. Have you been instructed in the use of protective equipment?
YesNo
12. Do you wash your hands with solvents?
YesNo
13. Do you smoke at the workplace?
YesNo
At home?
YesNo
14. Are you exposed to secondhand tobacco smoke at the workplace?
YesNo
At home?
YesNo
15. Do you eat at the workplace?
YesNo
16. Do you know of any co-workers experiencing similar or unusual symptoms?
YesNo
17. Are family members experiencing similar or unusual symptoms?
YesNo
18. Has there been a change in the health or behavior of family pets?
YesNo
19. Do your symptoms seem to be aggravated by a specific activity?
YesNo
20. Do your symptoms get either worse or better at work?
YesNo
at home?
YesNo
on weekends?
YesNo
on vacation?
YesNo
21. Has anything about your job changed in recent months (such as duties, procedures, overtime)?
YesNo
22. Do you use any traditional or alternative medicines?
YesNo
If you answered yes to any of the questions, please explain.
Part 2. Work History
A. Occupational Profile
Name:
Birth date:
Not Set
Sex:
MaleFemale
The following questions refer to your current or most recent job:
Job title:
Type of industry:
Name of employer:
Date job began:
Not Set
Are you still working in this job?
YesNo
If no, when did this job end?
Describe this job:
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
Not Set
Not Set
Not Set
Not Set
Not Set
*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.
AcidsAlcohols (industrial)AlkaliesAmmoniaArsenicAsbestosBenzeneBerylliumCadmiumCarbon tetrachlorideChlorinated naphthalenesChloroformChloropreneChromatesCoal dustDichlorobenzeneEthylene dibromideEthylene dichlorideFiberglassHalothaneIsocyanatesKetonesLeadMercuryMethylene chlorideNickelPBBsPCBsPerchloroethylenePesticidesPhenolPhosgeneRadiationRock dustSilica powderSolventsStyreneTalcTolueneTDI or MDITrichloroethyleneTrinitrotolueneVinyl chlorideWelding fumesX-raysOther (specify)
B. Occupational Exposure Inventory
Please circle the appropriate answer.
1. Have you ever been off work for more than 1 day because of an illness related to work?
YesNo
2. Have you ever been advised to change jobs or work assignments because of any health problems or injuries?
YesNo
3. Has your work routine changed recently?
YesNo
4. Is there poor ventilation in your workplace?
YesNo
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?
YesNo
2. Which of the following do you have in your home?
Air conditionerAir purifierCentral heating (gas or oil?)Gas stoveElectric stoveFireplaceWood stoveHumidifier
Please circle those that apply.
3. Have you recently acquired new furniture or carpet, refinished furniture, or remodeled your home?
YesNo
4. Have you weatherized your home recently?
YesNo
5. Are pesticides or herbicides used in your home or garden, or on pets?
YesNo
(bug or weed killers; flea and tick sprays, collars, powders, or shampoos)
6. Do you (or any household member) have a hobby or craft?
YesNo
7. Do you work on your car?
YesNo
8. Have you ever changed your residence because of a health problem?
YesNo
9. Does your drinking water come from a private well, city water supply, or grocery store?
YesNo
10. Approximately what year was your home built?
If you answered yes to any of the questions, please explain.
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