Exposure History Form

Subjective:
Chief Complaint:
Chronic lower back pain and depressive 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).

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.

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

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

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)

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

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

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

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

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

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

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

If yes, list the protective equipment used.

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

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

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

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

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

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

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

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

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

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

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

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

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

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?

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

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 (bug or weed killers; flea and tick sprays, collars, powders, or shampoos) used in your home, garden, or on pets?

6. Does your drinking water come from a private well?

7. Approximately what year was your home built?

8. Have you ever changed your residence because of a health problem?

Hobbies:
9. Do you (or any household member) have a hobby or craft?

10. Do you work on your car?

Personal:
11. Do you wear any products with fragrances? If so, which brands do you use?

12. Which laundry detergent or fabric softener do you use, if any?

Diet:
13. Does your food come from somewhere other than a grocery store?

14. What does your diet consist of mainly? [organic/non-organic] [processed/whole foods]

15 Are there any foods that you do not eat? If so, why not?

16. What is your weekly fish intake?

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?

18. Do you use any recreational drugs? If so, which ones?

If yes to any above, please explain.