Exposure History Form

Subjective:
Chief Complaint:
Fatigue and associated symptoms

Exposure History Form - Part 1: Exposure Survey:
Please fill in the patient's name, birth date, date of survey, and sex (select one: Male or Female).

Patient's name: Ms. Parker
Birth date: 
Date of survey: 2026-02-08
Sex: Female

1. Are you currently exposed to any of the following? (Select yes or no for each): metals, dust or fibers, chemicals, fumes, radiation, biologic agents, loud noise/vibration/extreme heat or cold. 
No information available

2. Have you been exposed to any of the above in the past? (yes/no)
No information available

3. Do any household members have contact with metals, dust, fibers, chemicals, fumes, radiation, or biologic agents? (yes/no)
No information available

If yes to any above, describe your exposure in detail: how you were exposed, to what, how much, how often, and duration.

4. Do you know the names of the metals, dusts, fibers, chemicals, fumes, or radiation you are/were exposed to? (yes/no)
No information available

5. Do you get the material on your skin or clothing? (yes/no)
No information available

6. Are your work clothes laundered at home? (yes/no)
No information available

7. Do you shower at work? (yes/no)
No information available

8. Can you smell the chemical or material you are working with? (yes/no)
No information available

9. Do you use protective equipment such as gloves, masks, respirator, or hearing protectors? (yes/no)
No information available

10. Have you been advised to use protective equipment? (yes/no)
No information available

11. Have you been instructed in the use of protective equipment? (yes/no)
No information available

If yes, list the protective equipment used.

12. Do you wash your hands with solvents? (yes/no)
No information available

13. Do you smoke at the workplace? (yes/no) and at home? (yes/no)
No information available

14. Are you exposed to secondhand tobacco smoke at the workplace? (yes/no) and at home? (yes/no)
No information available

15. Do you eat at the workplace? (yes/no)
No information available

16. Do you know of any co-workers experiencing similar or unusual symptoms? (yes/no)
No information available

17. Are family members experiencing similar or unusual symptoms? (yes/no)
No information available

18. Has there been a change in the health or behavior of family pets? (yes/no)
No information available

19. Do your symptoms seem to be aggravated by a specific activity? (yes/no)
No information available

20. Do your symptoms get worse or better at work, at home, on weekends, or on vacation? (yes/no for each)
No information available

21. Has anything about your job changed recently (duties, procedures, overtime)? (yes/no)
No information available

22. Do you use any alternative medicines such as herbs or natural supplements? (yes/no)
No information available

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

24. Do you have any other allergens, intolerances, or chemical sensitivities not listed? [yes/no] If so, which ones? [Perfumes, Pesticides, Petrochemicals, Plastics]
No information available

If yes to any above, please explain.

Exposure History Form - Part 2: Work History:
A. Occupational Profile

Please provide details about 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:

B. Employment History Table

List all jobs you have worked including short-term, seasonal, part-time employment, and military service, starting with the most recent.

For each job, provide:
- Dates of employment
- Job title and description of work
- Exposures (list chemicals, dusts, fibers, fumes, radiation, biologic agents, physical agents such as extreme heat, cold, vibration, noise)
- Protective equipment used

C. Occupational Exposure Inventory

Please answer yes or no to the following:
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 health problems or injuries?
3. Has your work routine changed recently?
4. Is there poor ventilation in your workplace?

D. Exposure to Specific Agents

Have you ever worked at a job or hobby where you came in contact with any of the following by breathing, touching, or ingesting? Please select yes or no for each:
- Acids
- Alc (alcohols)
- Alk (alkalies)
- Ammonia
- Arsenic
- Asbestos
- Benzene
- Beryllium
- Cadmium
- Carbon tetrachloride
- Chlorinated naphthalenes
- Chloroform
- Chloroprene
- Chromates
- Coal dust
- Dichlorobenzene
- Ethylene dibromide
- Ethylene dichloride
- Fiberglass
- Halothane
- Isocyanates
- Ketones
- Lead
- Mercury
- Methylene chloride
- Nickel
- PBBs
- PCBs
- Perchloroethylene
- Pesticides
- Phenol
- Phosgene
- Rock dust
- Silica powder
- Solvents
- Styrene
- Toluene
- TDI or MDI
- Trichloroethylene
- Trinitrotoluene
- Vinyl chloride
- Welding fumes
- X-rays
- Other (specify)

If yes to any, please specify details.

Exposure History Form - Part 3: Environmental History:
Community:
1. Do you live next to or near an industrial plant, commercial business, dump site, or nonresidential property?
No information available

Home:
2. Which of the following do you have in your home? (Select all that apply):
- Air conditioner
- Air purifier
- Central heating (specify gas or oil)
- Gas stove
- Electric stove
- Fireplace
- Wood stove
- Humidifier
No information available

3. Have you recently acquired new furniture or carpet, refinished furniture, or remodeled your home?
No information available

4. Have you weatherized your home recently?
No information available

5. Are pesticides or herbicides (bug or weed killers; flea and tick sprays, collars, powders, or shampoos) used in your home, garden, or on pets?
No information available

6. Does your drinking water come from a private well?
No information available

7. Approximately what year was your home built?
No information available

8. Have you ever changed your residence because of a health problem?
No information available

Hobbies:
9. Do you (or any household member) have a hobby or craft?
No information available

10. Do you work on your car?
No information available

Personal:
11. Do you wear any products with fragrances? If so, which brands do you use?
No information available

12. Which laundry detergent or fabric softener do you use, if any?
No information available

Diet:
13. Does your food come from somewhere other than a grocery store?
No information available

14. What does your diet consist of mainly? [organic/non-organic] [processed/whole foods]
No information available

15 Are there any foods that you do not eat? If so, why not?
No information available

16. What is your weekly fish intake?
No information available

Drugs:
17. Do you take any medication as prescription or over-the-counter? Are you allergic or sensitive to any medications, either prescription or over-the-counter?
No information available

18. Do you use any recreational drugs? If so, which ones?
No information available

If yes to any above, please explain.