Patient: Maria Gonzalez
Person completing this form: Alicia Gonzalez

Community Exposures

Do you live next to or near an industrial plant, commercial business, dump site, or non-residential property? Yes No ___ If yes, please explain:

Pursue further? Yes No

Where does your drinking water come from? a private well? ___ city water supply? grocery store? ___

Pursue further? Yes No

Home Exposures

General

Have you ever changed your residence because of a health problem? Yes___ No If yes, please explain:

Pursue further? Yes No

Consumer Products

Does anyone in the household smoke in the home? Yes ___ No If yes, how many packs per day?

Pursue further? Yes No

Have you recently acquired new furniture or carpet, refinished furniture, or remodeled your home? Yes ___ No If yes, please explain:

Pursue further? Yes No

Are pesticides (bug or weed killers, flea and tick sprays, collars, powder, or shampoos) used in your home, on your garden or lawn, or on pets? Yes ___ No If yes, please explain:

Pursue further? Yes No

Hobbies/Crafts

Do you (or any household member) have a hobby or craft? Yes No ___ If yes, please explain:

Pursue further? Yes No

Do you work on your car? Yes___ No If yes, please describe what work you do on your car.

Pursue further? Yes No

Building Materials

Approximately what year was your home built?

Pursue further? Yes No

Heating/Cooling System

Please check if you have the following in your home: Air conditioner ___ Air purifier ___ Humidifier ___ Cooking stove: Gas ___ Electric Central heating: gas ___ oil electric ___ Water heater: gas oil ___ electric ___ Supplemental heating: kerosene ___ wood stove Other ___ Fireplace ___

Pursue further? Yes No

Take-Home Toxins

List the current occupation and employer of everyone living in the house who works outside the home.

Is anyone in the home besides the patient exposed to hazardous substances at work? Yes ___ No ___ Don't know If yes, please list the substances if you know.

Pursue further? Yes No

Are other family members experiencing similar or unusual symptoms? Yes ___ No If yes, please explain:

Pursue further? Yes No