OCCUPATIONALHISTORY

NAME: DATE: DateofBirth: day month year CurrentJobTitle/ Employer: Typeof Industry:

Length ofTimeatCurrentJob:

EmploymentStatus:

ΟFulltimeΟRegular HoursΟRegular Duties

ΟPart-timeΟModifiedHoursΟModifiedDuties

Doyou undergo anyroutinemedicaltestsat work?YesΟNoΟ

If yeswhich one(s) and why? (silica,lead,isocyanates, asbestos,other)

ΟHearingtestsΟChest x-raysΟPulmonaryFunctionTests

ΟBloods testsΟOther

Doyou wearPersonalProtective Equipment?YesΟNoΟ

If yes,whichone(s):

ΟGlovesΟCoverallsΟSafetyGlassesΟHearingProtection

ΟMaskΟRespiratorΟSafetyShoesΟOther_

Check ifyou are exposed to anyof thefollowing:

ΟFumes / ΟAnimals / Ο LoudNoises
ΟDust / ΟVibration / ΟExtremeHeat/Cold
ΟChemicals / ΟRadiation / ΟPesticides
ΟSolvents / ΟNanofibers / ΟMetalWorkingFluids
ΟRepetitivemovement/lifting / ΟOTHER

Doyou thinkthat anyaspect ofyourhealth is aggravatedby your work?

ΟYes ΟNo

Pleaselist anyotherjobs you havehadin the past,includedates (years),titleand your job description (welding,painting, etc.)

DATESEMPLOYERJOBTITLEJOBDESCRIPTION

PurposeofTemplate

The purpose of this template is to provide a permanent record of hazardous exposuretoapatientandtoassistinidentifyingcurrentrisksfromthatexposurethat mayintimeleadtoadisease. Itmaybeusefulasateaching toolwithinthedoctor patientinteraction.It willalsoassistinthe preventionofwork-relateddiseases.

Diseasesrelatedtohazardousexposuresarepreventable. Inmanycasesthe causeofadiseasegoesundetected. Inothercasesthelengthoftimebetween exposuresandthedevelopment ofadiseaseissolongthattheexposureisoften forgottenandtherecordkeepingofanexposureisinvaluableindeterminingthe causeoftheillness.

Explanation/ExamplesofHazardousExposures

Fumes/Gases vaporoussubstances,suchascarbonmonoxide,sulphurdioxide, nitrousdioxide,disinfectants,chlorinegas,firesmokeandwelding.

Dustoccupational pulmonary diseasemayberelatedtoexposurestosilica, asbestos,non-organicdust,graindust,orotherrespiratoryirritants.

Chemicalsabroadcategory ofelementsorcompounds obtainedbyachemical process,includingorganic/inorganic compounds,polymers,andcompoundswhich maynototherwisebelistedinthecategoriesbelow.

Pesticideschemicalsubstances,suchasorganophosphates, carbamates, organochlorines,bipyridyls,andfumigants.

Solventsa largegroupof chemicalsubstanceswhichdissolveothermaterials,

includingaromatichydrocarbons (benzene,toluene,xylene,etc.)andchlorinated hydrocarbons.

Animalscontactwithwildordomestic animals maybeasourceofillnesssuchas psittacosis,lymedisease(tickwithanimalreservoirs),orallergicresponses.

Vibrationphysicalagentssuchassegmental vibrationexposuretothehandsand feet(eg.vibratorytools).

Radiationincludingionizingandnonionizingradiationexposure.

RepetitiveMovementactivitiesperformedonacontinuousorrepeatedbasis,such asliftingfromthewaistorflexion/extensionofthewristsagainstresistance.

LoudNoisesexposure mayincludeacuteortraumatic noise(suchasindustrial. explosion)orchronicnoise(suchasheavyequipmentorothermachinery).

ExtremeHeat/Coldoccupationalexposuretoextremesintemperature.