Styrene

Trinitrotoluene

Talc

Vibration

Toluene

Vinyl chloride

TDI or MDI

Welding fumes

Trichloroethylene

X rays

If you have answered ''yes" to any of the above, please describe your exposure on a separate sheet of paper.

Environmental Exposure
  1. Do you live in the central city or in a rural, urban, or suburban area?

  2. Have you ever changed your residence or home because of a health problem? If so, describe:

  3. Do you live in the immediate vicinity of a refinery, smelter, factory, battery recycling plant, hazardous waste site, or other potential pollution source?

  4. Do you (and your child) live in or regularly visit a building with peeling or chipped lead paint (e.g., built before 1960)? Has there been recent, ongoing, or planned renovation or remodeling of this structure(s)?

  5. Do any members of your household have contact with dusts or chemicals in the workplace that are then brought into the home?

  6. Do you have a hobby that you do at home? If so, describe:

  7. Do you fumigate your home or use pesticides in and around your home and on a pet? Do you use mothballs?

  8. What cleaning agents and solvents are used in your home?

  9. Is there evidence of mold in your home?

  10. Which of the following do you use in your home?

Air conditioner

Humidifier

Electric stove

Wood stove

Air purifier

Gas stove

Fireplace

Unvented kerosene heater or gas heater

  1. What is your source of drinking water?

Community water system

Private well

Bottled water



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