Date:

Last Name:

First Name:

Address:

Appt./Unit:

City: State: Zip:

SS#: Phone:

Birth date: Age:Gender: MaleFemale

B. MEDICAL HISTORY

1. Have you ever been in the hospital as a patient? YES NO

If YES, what kind of problem were you having?

2. Have you ever had any kind of operation? YES NO

If YES, what kind?

3. Do you take any kind of medicine regularly? YES NO

If YES, what kind?

4. Are you allergic to any drugs, foods, or chemicals? YES NO

If YES, what kind of allergy do you have?

     b) What triggers your allergy?

     YES NO

     YES NO

5. Have you ever been told that you have

     a) asthma, YES NO

     b) hayfever, YES NO or

     c) sinusitis?  YES NO

6. Have you ever been told that you have

     a) emphysema, YES NO

     b)bronchitis,  YES NO

     c)or any other respiratory problems?YES NO

7. Have you ever been told you had hepatitis? YES NO

8. Have you ever been told you had cirrhosis? YES NO

9. Have you ever been told that you had cancer? YES NO

10. Have you ever had arthritis or joint pain? YES NO

11. Have you been told that you had high blood pressure? YES NO

12. Have you ever had a heart attack or heart trouble? YES NO

YES NO

If YES, for what condition?

2. Have you been under the care of a physician

during the past three years? YES NO

If YES, for what condition?

3. Has there been any change in your breathing in the past year? YES NO

     BetterWorse

If there has been a change, do you know why?

4. Is your general health different this year compared to last year? YES NO

If YES, in what way?

5. Do you have any eye problems, such as itchiness,

dryness, inflammation? YES NO

If YES, please explain:

6. Do you have any skin problems, such as dryness,

itchiness, hives or reddish spots in the past year?YES NO

If YES, please explain

7. Have you, in the past year or are you now, taking

any medication on a regular basis? YES NO

If YES, please provide the name of the medication:

for what condition?

Years.

2. What jobs have you held with this employer? Include job title and length of time in each job.

3. In each of these jobs, how many hours a day were you exposed to chemical products?

4. What chemical product have you worked with most of the time?

Spray paint; Solvents Glues Paint Thinner

List others:

5. Have you ever noticed any type of skin rash you feel was related to your work?

YES NO

6. Have you ever noticed that some kinds of chemicals make you

a) cough? YES NO

b) wheeze? YES NO

c) short of breath? YES NO

d) experience chest tightness? YES NO

7. Are you exposed to any particular dust or chemicals at home?YES NO

If YES, please explain:

8. In other jobs, have you had exposure to:

wood dustchrome asbestos

organic solvents urethane foams

1. Are you working on the same job this year as you were last year? YES NO

If NO, how has your job changed?

b) How many hours do you work per week?  hours.

c) Where is your regular workplace located? Indicate bldg/floor/office/room.

2. What chemicals are you exposed to on your job?

3. How many hours a day are you exposed to chemicals?  hours.

4. Have there been any water leaks in your workplace ?YES NO

If YES, describe:

5. Have you noticed any visible stains on the walls? YES NO

6. Visible stains on the ceiling or ceiling tiles? YES NO

7. Does your work area have a musty odor? YES NO

8. Have you noticed mold or mildew?YES NO

If YES, explain:

9. Have you noticed any skin rash you feel was related to your work? YES NO

If YES, explain:

10. Have you noticed that any chemical makes you cough, be short of breath, or wheeze?YES NO

If YES, can you identify it:

Apartment  House Duplex  Coop

2. Age of buildingyears.

3. Type of heating:

Forced hot air  Water/steam  Electric Gas  Oil

4. How many people live in your household?   people.

5. Are there any smokers in your apartment/household? YES NO

6. Are there any pets in your apartment/household? YES NO

If YES, please specify:

7. Do you use pesticides (ant/roach control) chemicals at home? YES NO

8. Do you use a humidifier at home? YES NO

9. Do you have wall to wall carpeting in your home? YES NO

10. Have there been any water leaks in your home/apartment? YES NO

If YES, describe:

11. Have you notice visible stains on the walls? YES NO

12. Visible stains on ceiling tiles? YES NO

13. Does your home/apartment have a musty odor?YES NO

14. Have you noticed mold or mildew? YES NO

If YES, explain:

15. Have you had any air quality or environmental survey done

in your home / apartment? YES NO

If yes, what were the results?

1. Do you smoke? YES NO

     a) If YES: pipe cigars  cigarettes

     b) Please estimate the amount you smoke daily:per day.

     c) How many years have you been smoking? years.

2. Do you drink alcohol in any form? YES NO

     a) How often do you drink?

     Daily 5x per week 2x per week 1x per week Less than 1x per week

3. Do you wear glasses or contact lens? YES NO

4. Do you get any physical exercise (other than on your job)? YES NO

If YES, explain:

5. Do you have any hobbies or "side jobs" that require you to use chemicals, such as furniture stripping, sand blasting, insulation or manufacture of urethane foam, furniture, etc.? YES NO

If YES, please describe, giving type of business or hobby, chemical used, and length of exposure:

6. Are you physically affected by auto exhaust, perfumes, washing detergents, diesel fumes? YES NO

If YES, please describe:

1. Do you have any shortness of breath? YES NO

     a) If YES, do you have to rest after climbing several lights of stairs? YES NO

     b) If YES, when walking with people your own age, do you walk slower than them?

       YES NO

     c) If YES, if you walk slower than a normal pace, do you have to limit the distance that you walk? YES NO

     d) If YES, do you have to stop and rest while bathing or dressing? YES NO

2. Do you cough as much as three months out of the year? YES NO

     a) If YES, have you had this cough for more then two years? YES NO

     b) If YES, do you ever cough anything up from chest? YES NO

3. Do you have a feeling of smothering, unable to take a deep breath, or tightness in your chest? YES NO

     a) If YES, do you notice this on any particular day of the week? YES NO

If YES, what day of the week?

     b) If YES, do you notice that this occurs at any particular place? YES NO

     c) If YES, do you notice that this is worse after you have returned to work after being  off for several days? YES NO

4. Have you notice any wheezing in your chest? YES NO

     a) If YES, is this only with colds or other infections? YES NO

     b) Is this caused by exposure to any kind of dust or other material? YES NO

If YES, what kind?

5. Have you notice any burning, tearing, or redness of your eyes when you are at home? YES NO

If YES, explain circumstances:

6. Have you noticed any sore, itchy, burning throat or burning nose when you are at your home? YES NO

If YES, explain circumstances:

7. Have you noticed any stuffiness or dryness of your nose? YES NO

8. Do you ever have swelling of the eyelids or face? YES NO

9. Have you ever been jaundiced? YES NO

10. Have you ever had a tendency to bruise easily or bleed excessively? YES NO

11. Do you have frequent headaches that are not relieved by aspirin or TYLENOL?

YES NO

     a) If YES, do they occur at any particular time of the day or week? YES NO

If YES, when do they occur?

12. Do you have frequent episodes of nervousness or irritability? YES NO

13. Do you tend to have trouble concentrating or remembering? YES NO

14. Do you feel dizzy, light-headed, excessively drowsy or like you have been drugged? YES NO

15. Does your vision ever become blurred? YES NO

16. Do you have numbness or tingling of the hands, feet or other parts of your body? YES NO

17. Have you had excessive malaise or suffer from chronic fatigue? YES NO

Please explain:

18. Have you ever had any swelling of your feet or ankles to the point where you could not wear your shoes? YES NO

19. Are you bothered by heartburn or indigestion? YES NO

20. Do you ever have itching, dryness, or peeling and scaling of the hands?

YES NO

21. Do you ever have a burning sensation in the hands, or reddening of the skin?

YES NO

22. Do you ever have cracking or bleeding of the skin on your hands? YES NO

23. Are you under a physician's care? YES NO

If YES, for what are you being treated?

24. Do you have any physical complaints today? YES NO

If YES, explain

25. Do you have other health complaints or conditions not covered

by these questions?YES NO

If YES, explain

Work Environment:

During the last six months have you been bothered by any or several of the following factors in your work environment or home?

Drafts: Always Sometimes Never

High Room Temperature: Always Sometimes Never

Variable Room Temperature: Always Sometimes Never

Low Room Temperature: Always Sometimes Never

Stuffy "Bad" Air: Always Sometimes Never

Unpleasant Smell: Always Sometimes Never

Static Electricity Causing Shocks: Always Sometimes Never

Second Hand Smoke: Always Sometimes Never

Noise: Always Sometimes Never

Poor Lighting: Always Sometimes Never

Glare/Reflection: Always Sometimes Never

Dust and Dirt: Always Sometimes Never

Interesting and stimulating? Always Sometimes Seldom Never

Do you feel overburdened by your job duties and responsibilities?

Always Sometimes Seldom Never

Do you have any power or authority to define or change your work environmental condition?

Always Sometimes Seldom Never

Would you like to be contacted in the future to schedule an apt.?

YES NO

Is there any additional information you think we should know?