Environmental health

Taking an Exposure History

Exposure History Form

Part 1. Exposure Survey Name: Please select the appropriate answer. Birth date:

Date: Sex (select one): Male Female

1. Ar e 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

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, how much, how often, and how long you were exposed?

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, list them below

If yes, list the protective equipment used

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6/26/2021 09/07/1992

clisa daughtret

I was exposed to excessive heat on several ocassions while visting family in nevada. chemicals while doing house keeping at a hotel

gloves and mask

Taking an Exposure History

12. Do you wash your hands with solvents? no yes

13 Do you smoke at the workplace? no yes no yes

at home?

14 Are you exposed to secondhand tobacco smoke at the workplace? no yes no yesat home?

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 (such as herbs or natural supplements) alternative medicines? no yes

23. Have you or your child ever eaten non-food items such as paint, plaster, dirt and/or clay? no yes

If you answered yes to any of these questions, please explain.

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at home?

yes yes

yes yes

Taking an Exposure History

Part 2. Work History A. Occupational Profile

The following questions refer to your current or most recent job:

Job title:

Type of industry:

Name of employer:

Date job began:

Are you still working in this job? yes no

If no, date job ended?

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.

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 select beside the name.

Acids Chloroprene Methylene chloride Styrene Alc Chromates ohols (industrial) Nickel Talc Alk t alies Coal dus PBBs Toluene Ammonia Dichlorobenzene PCBs TDI or MDI Ar n c se i Ethylene dibromide Perchloroethylene Trichloroethylene Asbestos Ethylene dichloride Pesticides Trinitr luene Benzene la

oto Fiberg ss Phenol Vinyl chloride

Beryllium Halothane Phosgene Welding fumes

y)

Cadmium Isocyanates Radiation X-rays Carbon tetrachloride Ketones Rock dust Other (specif Chlorinated naphthalenes Lead Silica powder Chloroform Mercury Solvents

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housekeeping

hotel

days inn

08/22/2017

clean and sanatize rooms, bathrooms

08/22/2017-current Housekeeper chemicals, solvents, fumes, gas

gloves, mask

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Taking an Exposure History

B. Occupational Exposure Inventory Please select 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

Part 3. Environmental History Please select 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 select those that apply.

Air conditioner Air purifier Central heating ( Gas Oil) Gas stove Electric stove Fireplace Wood stove Humidifier

3. Have you recently acquired new furniture or carpet, refinished furniture, or remodeled

your home? no yes

4. Have you weatherized your h me recently? o 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? no yes no yes no yes no yes

10. Approximately what year was your home built?

11. Does your food come from somewhere other than a grocery store? no yes

I

f you answered yes to any of these questons, please explain.

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City water supply? Grocery store?

cityOther (specify)

1987