Exposure History Form

Chief Complaint

Exposure History Form

Form Content

Hello, my name is Emma, and I will help you complete the questionnaire portion of your Exposure History. The information that you provide will be summarized for your physician and is needed to complete the exam. We estimate this questionnaire will take around 20 minutes to complete. If you must stop, you can return at a later time to finish. If you want me to repeat a question, just say "repeat." Are you ready? Personal Information: 1. What is your full name? 2. What is your date of birth? Exposure History: 3. Do you have any of the following exposures at home or work? Asbestos, Lead, Mold, Pesticides, Solvents, Heavy metals, Radiation Yes/No (If no, move on. If yes, ask: "Please provide details about which ones and any relevant information." only if the user does not provide further details after saying yes.) 4. Do you currently work or have you ever worked in any of the following industries? Construction, Agriculture, Manufacturing, Healthcare, Mining, Chemical industry Yes/No (If no, move on. If yes, ask: "Please provide details about which ones and any relevant information." only if the user does not provide further details after saying yes.) 5. Have you been exposed to any of the following substances through hobbies or activities? Painting, Gardening, Welding, Woodworking, Fishing, Hunting Yes/No (If no, move on. If yes, ask: "Please provide details about which ones and any relevant information." only if the user does not provide further details after saying yes.) 6. Do you use any personal protective equipment (PPE) such as masks, gloves, or respirators when exposed to chemicals or dust? Yes/No (If no, move on. If yes, ask: "Please describe which PPE you use and how often." only if the user does not provide further details after saying yes.) 7. Have you noticed any symptoms that you believe are related to your exposures? Yes/No (If no, move on. If yes, ask: "Please describe the symptoms and their severity." only if the user does not provide further details after saying yes.) Environmental Factors: 8. Do you have any of the following environmental exposures at home? Radon, Secondhand smoke, Air pollution, Water contamination Yes/No (If no, move on. If yes, ask: "Please provide details about which ones and any relevant information." only if the user does not provide further details after saying yes.) 9. Do you live near any industrial sites, waste disposal areas, or heavy traffic roads? Yes/No (If no, move on. If yes, ask: "Please provide details about the location and duration of residence." only if the user does not provide further details after saying yes.) Lifestyle Factors: 10. Do you smoke or have you ever smoked tobacco products? Yes/No (If no, move on. If yes, ask: "Please provide details about the duration and amount." only if the user does not provide further details after saying yes.) 11. Do you consume alcohol? Yes/No (If no, move on. If yes, ask: "Please provide details about frequency and amount." only if the user does not provide further details after saying yes.) 12. Do you use recreational drugs? Yes/No (If no, move on. If yes, ask: "Please provide details about which drugs and frequency." only if the user does not provide further details after saying yes.) Medical History: 13. Do you have any of the following medical conditions? Asthma, Chronic bronchitis, Allergies, Skin conditions, Neurological symptoms Yes/No (If no, move on. If yes, ask: "Please provide details about which ones and any relevant information." only if the user does not provide further details after saying yes.) 14. Are you currently taking any medications related to your exposures or symptoms? Yes/No (If no, move on. If yes, ask: "Please list the medications and dosages." only if the user does not provide further details after saying yes.) 15. Have you had any previous medical evaluations or treatments related to environmental exposures? Yes/No (If no, move on. If yes, ask: "Please provide details about the evaluations or treatments." only if the user does not provide further details after saying yes.) Additional Information: 16. Please upload any relevant medical reports or images you would like the doctor to review. End. (Show the following information when questionnaire complete) Thank you for completing the questionnaire. We’ll share this information with your healthcare provider.