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T o t H e r u s (Advance Biomedical Treatment Center)

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a
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A
A
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E
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x
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p
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A mnemonic (CH
2
OPD
2
) helps to organize the
history, and the forms below can be given to
patients to be completed at home and reviewed
at a subsequent educational counseling visit.
C
o
o
m
m
m
m
u
u
n
n
i
i
t
t
y
y
H
H ome
H
H obby
O
O ccupation
P
P ersonal
D
D iet
D
D rugs
Environmental Health Clinic, Sunnybrook & Women’s College Health Sciences Centre compiled by Dr. L. M. Marshall
Ontario College of Family Physicians print design by Helen Kwan
Exposure History
C
C
O
O
M
M
M
M
U
U
N
N
I
I
T
T
Y
Y
For each of the items
listed below:
Do you presently live nearby
If you ever lived
nearby, please
write the years.
Heavy traffic
T No T Yes (please specify)
P highway P busy street
Vehicle idling area
T No T Yes (please specify)
P auto P bus / truck
Dump site
T No T Yes (please specify type)
Farm(s)
T No T Yes (please specify type)
Industrial plant(s)
T No T Yes (please specify type)
Polluted lake / stream
T No
T Yes (please specify type)
Nuclear power plant
T No T Yes
Hydro towers
T No T Yes
Other potential hazards
T No T Yes (please specify type)
Do you protect yourself from excess sun exposure? T rarely T occasionally T often T always
H
H
O
O
M
M
E
E
&
&
H
H
O
O
B
B
B
B
Y
Y
How long have you lived in your present residence? How old is it?
What type of dwelling is your residence? T house T mobile home
T apartment ® P basement P above store P highrise ® floor ______
Ownership? T owner occupied T rental T public housing
How is your home heated? T forced air T hot water radiators T space heater T baseboard heaters
What type of fuel is used for heating? T natural gas T oil T wood T electricity T propane
Do you use:
T central vacuum? T HEPA filter vacuum? T other vacuum? ______________________
Have you done any renovating?
T No T Yes ® When? ________________________________
What? _________________________________
Do you own / lease a car?
T No T Yes ® Age? _________ Smoking permitted inside? P No P Yes
Do you use pesticides or herbicides (bug or weed killers, flea / tick sprays, collars, powders, pellets, etc.):
{ in your home?
T No T Yes (please specify type) _________________________________________________
| on your pets?
T No T Yes (please specify type) _________________________________________________
} on your lawn or garden?
T No T Yes (please specify type) _________________________________________
What is your water source for bathing?
T city T well T other (please specify ______________________)
Environmental Health Clinic, Sunnybrook & Women’s College Health Sciences Centre compiled by Dr. L. M. Marshall
Ontario College of Family Physicians print design by Helen Kwan
For each of the items listed below: Do you presently have in your HOME?
If you ever had, please
write the years.
Basement cracks or dirt floor
T No T Yes (circle which one or both)
Damp, musty basement or crawl space
T No T Yes ® P slight P severe
T No T Yes ® P slight P severe
T No T Yes ® P slight P severe ® Where?
T No T Yes ® P slight P severe ® Where?
T No T Yes ® P slight P severe
T No T Yes ® P slight P severe
T No T Yes ® P slight P severe
T No T Yes (circle which one or both)
T No T Yes (please specify)
T No T Yes (circle which one or both)
T No T Yes
T No T Yes ® P central P individual rooms
T No T Yes
T No T Yes (please specify)
T No T Yes ® Where? (e.g. basement,
your bedroom, etc.)
How old?
T No T Yes
T No T Yes ® Type(s)?
T No T Yes ® P attached P underground
T No T Yes ® Who?
T No T Yes (please specify kind & number)
T No
T Yes
Wet windows or outside closet walls
(condensation)
Water leaks
Visible mold
Crumbling pipe insulation
Flaking paint
Stagnant stuffy air
Gas or propane stove
Other gas appliances
Wood stove or fireplace
Carbon monoxide detector(s)
Air conditioning
Electrostatic air cleaner
Other air cleaner(s)
Carpets
Old vinyl linoleum
Photocopier / fax machine / printer
Garage
Smoker(s)
Pets
Pets sleep in your bedroom
Indoor plants
T No T Yes ® How many?
Do you use an electric blanket? T No T Yes ® Years ___________
Do you use dust mite-proof: Pillow cover(s)? T No T Yes Mattress cover(s)? T No T Yes
Age of your mattress __________________
What product(s) do you usually use: (please specify brands)
bathroom cleanser floor / wall cleanser
laundry detergent fabric softener
What hobbies do you have?
What hobbies do members of your household have?
Have you ever personally done any of the following:
T furniture stripping / refinishing
Years: _________
T home renovating
Years: _________
(please specify type) __________________________________
T art work (e.g. painting, ceramics,
stained glass, leather work, etc.)
Years: _______
__
(please specify type) __________________________________
T other non-occupational activities with exposure to toxic chemicals
Years:
(please specify type)
Environmental Health Clinic, Sunnybrook & Women’s College Health Sciences Centre compiled by Dr. L. M. Marshall
Ontario College of Family Physicians print design by Helen Kwan
O
O
C
C
C
C
U
U
P
P
A
A
T
T
I
I
O
O
N
N
1. Do you presently do volunteer work and/or work for pay? T Yes T No
T Volunteer work ® Number of hours per week:
Type:
If
yes,
T Work for pay ® Number of hours per week:
T Unable to work for pay due to health problems ® Date stopped work:
Reason(s):
T unresolved
If
no,
T On disability benefits ® Type:
OR
Disability claim ®
T permanently denied
2. Starting with your present or most recent job, please list all of the paying jobs you have ever had.
Please use the back of this page if necessary.
Company Name & Work Location
From
Mth / Yr
To
Mth / Yr
Job Title &
Description
Exposures*
Protective Measures /
Equipment **
1. / /
2. / /
3. / /
4. / /
* Please list the significant chemicals, dusts, fibres, fumes, radiation, biologic agents (e.g. bacteria, moulds, viruses) and physical agents
(e.g. extreme heat, cold, vibration, noise) that you were exposed to at this job.
** Please list any protective measures taken (e.g. showering at work, laundering clothes at work, etc.) or protective equipment used (e.g.
gloves, apron, mask, respirator, hearing protectors, etc.).
3. The following questions are about your present or most recent work environment:
Age of Building: Number of Floors: Approximate number of occupants:
Neighbourhood:
T rural T commercial T industrial
Which of the following are / were on the same floor as your work station in your present or most
recent work environment?
T bank of computers
T unvented smoking areas
T central air conditioning
T partitions or room dividers T unvented copy machines
T carpets ® How old?_____________
T windows that open
Can / could you smell odours from the following in your present or most recent work
environment?
T laboratory T cafeteria T manufacturing area T parking garage in or near the building
Have any of the following occurred in your work environment over the past 12 months or the
last 12 months you worked in your most recent job?
T use of pesticides ® P indoors P outdoors T fire, smoke T flood, water leaks T carpet cleaning
T new flooring, furniture, etc. (please specify) ________________________ T construction T renovation
T painting T chemical spill, leak (please specify) _______________ T accidents T stress
On average
, how would you describe your present or most recent work environment?
Lighting
T too much glare T satisfactory T too dim
Temperature
T too hot T satisfactory T too cold T too variable
Air Movement
T too stuffy T satisfactory T too drafty
Humidity
T too dry T satisfactory T too humid
Odour
T none T moderate T strong
Specify:
Noise
T little T moderate T a lot
Your Comfort Overall
T unsatisfactory T somewhat satisfactory T satisfactory
Co-workers’ Comfort Overall
T unsatisfactory T somewhat satisfactory T satisfactory
Environmental Health Clinic, Sunnybrook & Women’s College Health Sciences Centre compiled by Dr. L. M. Marshall
Ontario College of Family Physicians print design by Helen Kwan
S
S
C
C
H
H
O
O
O
O
L
L
(if applicable)
How old is your or your child’s school? _________ Number of floors: _________ Number of occupants: _________
Have additions been made to the original building?
T No T Yes ® When? _____________________
Number of portable classrooms in use: _____________
Hours per day you or your child spends in a portable classroom: _____________
School neighbourhood:
T rural T suburban T urban
Is your or your child’s school located near any of the following:
Heavy traffic
T No T Yes (please specify)
P highway P busy street
Vehicle idling area
T No T Yes (please specify)
P auto P bus / truck
Dump site
T No T Yes (please specify type)
Farm(s)
T No T Yes (please specify type)
Industrial plant(s)
T No T Yes (please specify type)
Polluted lake / stream
T No T Yes (please specify type)
Nuclear power plant
T No T Yes
Hydro towers
T No T Yes
Other potential hazards
T No T Yes (please specify type)
Which of the following does your or your child’s school have?
(Please check all that apply)
T carpeted classrooms T central air conditioning T art room – exhaust hood? P No P Yes
T unvented copy machine(s) T windows that open T laboratory – exhaust hood? P No P Yes
T flaking paints T mouldy smell T workshop – exhaust hood? P No P Yes
Have any of the following occurred in your or your child’s school during the current or last school year?
(Please check all that apply)
T carpet cleaning T construction T renovation T painting
T new flooring or furniture (please specify) ______________________ T flood, water leaks
T roof tarring T use of pesticides / herbicides ® P indoors P outdoors
Are the following products used in your or your child’s school during the school year?
(Please check all that apply)
T deodorizer strips T furniture wax or polish T odourous cleaning products
T floor wax T scented washroom soap T spray paints
T permanent markers T strong-smelling art supplies
Does your or your child’s school have a policy regarding the use of personal scented products by staff and
students?
T No T Yes (please specify) ® P prohibition of scented products P encouragement of unscented products
Environmental Health Clinic, Sunnybrook & Women’s College Health Sciences Centre compiled by Dr. L. M. Marshall
Ontario College of Family Physicians print design by Helen Kwan
Exposure History
P
P
E
E
R
R
S
S
O
O
N
N
A
A
L
L
Natural Inhalant Allergies
Do you think you are allergic to any seasonal pollens, animal danders, dust, mites, or moulds?
T No T Yes (please specify which) ______________________________________________________
Have you ever had allergy tests? T No T Yes
If
YES, please specify:
Age Year Type of Test Results
Treatments
(e.g. avoidance, shots,
medications)
Improvement
0 = worse 1 = none 2 = a little
3 = some 4 = a lot
Synthetic Chemicals
Have you ever had symptoms you linked with exposure to any synthetic (man-made) chemical at a level that
did not seem to bother most people (e.g. paints, perfumes, cosmetics, diesel exhaust, jet fuel, tar, etc.)?
T No T Yes
‘Linked’ means that the symptom started or worsened within 48 hours after you were exposed to something, or the
symptom improved or disappeared after you were no longer exposed to it.
‘Exposure’ means being near, touching, smelling, breathing in, eating, drinking, swallowing or injecting something.
If YES, please specify chemical(s) and symptom(s):
Man-made Chemical
Symptoms Linked with
Low Level Exposure
Presently Affected?
1 = a little 2 = somewhat 3 = a lot
In the Past
1 = a little 2 = somewhat 3 = a lot
How often do you use SCENTED personal products? (please check)
Scented
Products
Soap Lotion Cosmetics Hair permanent Hair tint Perfume/aftershave
Other(s)
(please specify)
Never
T T T T T T
T _____________
Occasionally
T T T T T T
T _____________
Daily
T T T T T T
T _____________
Artificial Materials
How many metal dental fillings / caps do you currently have? silver / mercury __________ gold __________
Have you had silver / mercury fillings removed?
T No T Yes ® Number removed: ______ Year(s): __________
Do you have other artificial materials in your body (e.g. pins, screws, plates, meshes, valves, implants, etc.)?
T No T Yes (please specify) ______________________________________________________________
Smoking History
Do you currently use tobacco (daily or almost every day)?
T No T Yes (please specify) ® P cigarettes P cigars P pipe P snuff P chewing tobacco
• If YES, average number per day: ________________ Number of years: ______
• If
NO, have you ever used tobacco (daily or almost every day)? P No P Yes
· If YES, number of years you used tobacco: _______________ Average number per day: ________________
· Date you last used tobacco regularly: Year _______________
Have you ever experimented with “recreational drugs”? T No T Yes
Environmental Health Clinic, Sunnybrook & Women’s College Health Sciences Centre compiled by Dr. L. M. Marshall
Ontario College of Family Physicians print design by Helen Kwan
Travel Illnesses
Have you ever experienced significant symptoms when travelling? T No T Yes
If
YES, please specify:
Age Year Location Symptoms
Blood Transfusion
Have you had blood transfusion(s)? T No T Yes ® Year(s) ____________________
Living Situation / Supports
Who lives at home with you? ______________________________________________________________
Are you:
T single T married / cohabitating T separated T divorced T widowed
Do you have spiritual beliefs / practices which help you cope?
T No T Yes (please comment) _____________________________________________________________
Are you part of a religious community which helps you cope?
T No T Yes (please estimate the number of contacts in the last 12 months) _____________________________
Who backs you up best with your present health problems? _________________________________________
What other supports do you have? ______________________________________________________________
Stresses
Type of Stress Ever had it?
When?
Please specify Year(s)
Comments
Loss of someone close
T No T Yes
Illness in someone close
T No T Yes
Loss of job
T No T Yes
Change of job
T No T Yes
Change of workplace
T No T Yes
A move
T No T Yes
Marriage
T No T Yes
Separation
T No T Yes
Divorce
T No T Yes
Pregnancy
T No T Yes
Alcohol / drug addiction
T No T Yes
Alcohol / drug addiction in
someone close
T No T Yes
Physical abuse
T No T Yes
Emotional abuse
(being put down, called names)
T No T Yes
Sexual abuse
T No T Yes
Other (please specify)
T No T Yes
Environmental Health Clinic, Sunnybrook & Women’s College Health Sciences Centre compiled by Dr. L. M. Marshall
Ontario College of Family Physicians print design by Helen Kwan
Exposure History
D
D
I
I
E
E
T
T
&
&
D
D
R
R
U
U
G
G
1. Who grocery shops for you? _________________________________________________________________
Where?
T chain grocery store T health food store T market T others (please specify) _________________
2. Who cooks for you? ________________________________________________________________________
3. Please indicate foods and beverages most typically consumed for each of the following meals and the
times at which they are most typically eaten.
Foods / Snacks
Please Specify
Time Beverage(s)
Please Specify
Time
Breakfast Breakfast
Mid-Morning Mid-Morning
Lunch Lunch
Mid-Afternoon
Mid-
Afternoon
Dinner Dinner
Evening Evening
4. How much of the following beverages do you consume regularly and have you linked any symptoms with
drinking them?
T water ® Number of 8 oz glasses per 24 hours _______ P city P charcoal-filtered P distilled P reverse osmosis
P bottled (glass) P bottled (plastic) Any symptoms linked? ______________________________
T beer, ale ® Number of 12 oz bottles per week _______ Any symptoms linked? ___________________________
T wine ® Number of 6 oz glasses per week _______ Any symptoms linked? _______________________________
T spirits (e.g. whisky, rum) ® Number of 1½ oz drinks per week ______ Any symptoms linked? ________________
T coffee ® Number of 8 oz cups per 24 hours _______ Any symptoms linked? ____________________________
T tea ® Number of 8 oz cups per 24 hours _______ Any symptoms linked? _______________________________
T cola ® Number of 12 oz drinks per 24 hours _____ P regular P diet Any symptoms linked? ________________
T other(s) (please specify) ________________________________ Any symptoms linked? ____________________
5. Do you eat fish or seafood? T No T Yes ® On average, how many days per week? ____ How many times per day? _______
Type(s) of fish or seafood eaten (e.g. tuna, salmon, shrimps, oysters, etc.): _________
6. Do you use artificial sweetener? T No T Yes ® On average, how many days per week? _____________________________
How many times per day? _______ Type(s) of sweetener: ______________
7. Please list foods / beverages that do not agree with you (e.g. stuffy runny nose, heartburn, bloating, diarrhea, sleepiness,
difficulty thinking or concentrating, etc.)
or cause allergic reactions (e.g. hives, rashes, shortness of breath, wheezing, anaphylaxis, etc.):
Approximately how often do you eat / drink them? List foods / beverages that are a
problem
What problem(s) do they
give you? Never Occasionally Daily More than once a day
8. Please list any foods / beverages that you crave or that help you to feel better and the time(s) the craving
usually occurs:
Approximately how often do you eat / drink them?
List foods / beverages that you
crave or that help you to feel better
Time(s)
of craving
What problem(s), if any,
do they give you?
Never Occasionally Daily
Environmental Health Clinic, Sunnybrook & Women’s College Health Sciences Centre compiled by Dr. L. M. Marshall
Ontario College of Family Physicians print design by Helen Kwan
9. Please list all PRESCRIPTION medications you currently take on a regular basis, including birth control
pills and allergy injections: *
Name of prescription medication
Dose
(e.g. mg, ml, IU)
How often do you take it?
How long have
you taken it?
If you have side effects,
please specify
* Use additional paper if necessary.
10. Please list all NON-PRESCRIPTION medications you currently take on a regular basis, including
vitamins, minerals, herbs, remedies, etc.: *
Name and brand of
non-prescription medication
Dose
(e.g. mg, ml, IU)
How often do you take it?
How long have
you taken it?
If you have side effects,
please specify
* Use additional paper if necessary.
11. Drug Adverse Reactions: Please list ANY medication / anesthetics / immunizations you have had to stop
taking because of side effects or allergic reactions:
Name of medication / immunization Type of side effects or allergic reaction that caused you to stop it Age Year
12. Have you EVER had an emergency injection of adrenaline (epinephrine) for a reaction to any medication,
food, insect sting, or other substance?
T No T Yes ® What year(s)?_________________________________________________________________
To what?_____________________________________________________________________
Environmental Health Clinic, Sunnybrook & Women’s College Health Sciences Centre compiled by Dr. L. M. Marshall
Ontario College of Family Physicians print design by Helen Kwan
Exposure History References
1. American Academy of Environmental Medicine. Allergy Database and Health History.
AAEM, Inc., Wichita, Kansas, 1992.
2. Anthony Honor, Birtwistle Sybil, Eaton Keith, Maberly Jonathan. Environmental Medicine
in Clinical Practice. BSAENM Publications (PO Box 28, Totton, Southampton, SO40 27A, Tel: 01
703 81 2124)
1997.
3. Bucsela J, Ed. Agency for Toxic Substances and Disease Registry. Case Studies in
Environmental Medicine: Taking an Exposure History. US Department of Health and
Human Services, October 1992.
4. Marshall LM, Mckeown-Eyssen G, Sokoloff E, Jazmaji V. University of Toronto Health
Survey. University of Toronto, Department of Public Health Sciences, 1995.
5. Miller CS, Prihoda TJ. The Environmental Exposure and Sensitivity Inventory (EESI):
A standardized approach for measuring chemical intolerances for research and clinical
applications, Toxicology and Industrial Health 15:370–385, 1999.
6. Miller CS, Prihoda TJ. A Controlled Comparison of Symptoms and Chemical
Intolerances reported by Gulf War Veterans, Implant Recipients and Persons with
Multiple Chemical Sensitivity, Toxicology and Industrial Health 15:386–397, 1999.
7. Quinlan P, Macher JA, Alevantis LE, Cone JE. Protocol for the Comprehensive
Evaluation of Building-Associated Illness in Occupational Medicine: State of the Art
Reviews, Vol. 4, No. 4, pp. 771–797, October – December 1989. Philadelphia, Hanley &
Belfus, Inc.
8. Raw GJ. Office Environment Survey. Construction Research Communications Ltd.
Building Research Establishment, Garston, Watford, WE27JR, 1995.
9. Small Bruce M. Recommendations for Action on Pollution and Education in Toronto: A
Report prepared for the Pollution and Education Review Group of the Board of
Education, the City of Toronto, May 1985.
10. Steel R, Belk S, Eds. Taking an Environmental History in Handbook of Pediatric
Environmental Health, American Academy of Pediatrics, 25–31, 1999.
Input from the Environmental Health Clinic Staff and Environmental Health Committee of the Ontario College
of Family Physicians is gratefully acknowledged.
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