Individual Health Exposure Assessment

Adapted from ACMT and ATSDR

Before your visit we would like to get some health information from you including a detailed occupational and environmental exposure history and a complete and accurate medical history. Please answer all the questions to the best of your ability. When you answer yes to any of the questions, please give details. The information you give about areas of your health is strictly confidential.

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Current Prescription Medications / Over-the-counter Medications / Herbs & Supplements

List all prescription medications, non-prescription medications, herbal medications, vitamins and supplements you are currently taking.

Medication 1
Medication 2
Add Another Medication
Allergies Or Reactions To Medicines/foods/other Agents
Add Another Allergy or Reaction
Past Medical History

Please check if YOU have ever been seen/treated by a healthcare provider for any of the following conditions and give the date it started:

Surgical History
Education Completed
Type of Diet
Exercise

How often do you exercise?

Family History

Please check if ANYONE IN YOUR FAMILY (parents, siblings) has a history of any of the following:

Occupational History
Worksite History

Please check If You Have Ever Worked In or Around the Following Activities:

Work History

Jobs with any potential exposures – Start with Most Recent

Job 1
Job 2
Add Another Work History
Work Questions
Chemical Exposure History

Please check If You are now exposed to or have ever worked with:

Other Possible Exposures History

Please check if any of the following are true:

Review of Symptoms

Must answer ONSET DATE of when symptoms started, if unsure, at least a year or say before drilling/after drilling. Add any additional details you can to explain.

Answer "N" (New) for any new symptoms, or if a symptom has become worse since drilling began then answer "W" (Worse). Also answer "O" (Ongoing) if the symptom is ongoing or "R" (Resolved) if it has been resolved.

    • Symptoms/Complaints
    • Date of Onset*
    • N
    • W
    • O
    • R
    • Details
  • General/Constitutional

    • Weight loss
    • Weight gain
    • Weakness/fatigue
    • Dizziness
    • Fever/chills/night sweats
    • Other
    • Symptoms/Complaints
    • Date of Onset*
    • N
    • W
    • O
    • R
    • Details
  • Dermatological

    • Skin rash/hives/blisters
    • Skin irritation/itchiness or burning
    • Skin cysts or growths
    • Dry skin
    • Other
    • Symptoms/Complaints
    • Date of Onset*
    • N
    • W
    • O
    • R
    • Details
  • Eyes, Ears, Nose, Throat

    • Eye irritation/itchy eyes/burning
    • Vision problems/blurry/floaters
    • Ringing in ears/hearing loss
    • Decrease sense of smell
    • Frequent runny nose/colds
    • Frequent sinus problems
    • Sore throat/throat irritation
    • Nose bleeds/gums bleed
    • Dry mouth/mouth irritation
    • Other
    • Symptoms/Complaints
    • Date of Onset*
    • N
    • W
    • O
    • R
    • Details
  • Respiratory and Cardiac

    • Persistent/frequent cough
    • Shortness of breath/rest/exertion
    • Wheezing/difficulty breathing
    • Decreased exercise tolerance
    • Increased heart rate
    • Decreased heart rate
    • Increased blood pressure
    • Decreased blood pressure
    • Heart palpitations/flutter
    • Chest pain
    • Other
    • Symptoms/Complaints
    • Date of Onset*
    • N
    • W
    • O
    • R
    • Details
  • Gastro-Intestinal/Urinary

    • Nausea
    • Vomiting
    • Abdominal pain
    • Heartburn/indigestion
    • Loss of appetite
    • Frequent diarrhea/constipation
    • Blood in stools/urine
    • Problems with urination
    • Other
    • Symptoms/Complaints
    • Date of Onset*
    • N
    • W
    • O
    • R
    • Details
  • Reproductive/Endocrine System

    • Infertility/loss of pregnancy
    • Period/menopause issues
    • Children with birth defects
    • Children with low birth wt/APGAR
    • Low testosterone
    • Hair loss (not age related)
    • Increased thirst
    • Increased sweating
    • Other
    • Symptoms/Complaints
    • Date of Onset*
    • N
    • W
    • O
    • R
    • Details
  • Neurological/Musculoskeletal

    • Headaches—details
    • Frequent falls/balance difficulties
    • Tremors (shakes/twitches)
    • Numbness and/or tingling
    • Confusion/memory loss
    • Concentration difficulties
    • Problems speaking
    • Muscle aches/cramps
    • Painful joints/swollen joints
    • Other
    • Symptoms/Complaints
    • Date of Onset*
    • N
    • W
    • O
    • R
    • Details
  • Blood System

    • Bruise easily
    • Prolonged bleeding
    • Symptoms/Complaints
    • Date of Onset*
    • N
    • W
    • O
    • R
    • Details
  • Psychological

    • Problems sleeping
    • Unusual moodiness/irritability
    • Anxiety/panic attacks
    • Depression/anger
    • Stress
    • Other