| * Indicates a required field | . |
| * Are you completing this form for another individual? | Yes No |
| If yes, please enter your contact information: Name: Phone: E-mail: | |
PART I - Personal History of the Affected Individual | |
| 1.
*Name: *Phone: *E-mail: | |
| 2. *Sex: | Male Female |
| 3. *Age Level: | Infant Child Adult Senior Citizen |
| 4. *Have you ever been diagnosed or treated for any respiratory or allergic condition? | Yes No |
| If YES, Please Explain: If NO, Please Skip to Question 5 | |
| Does the condition still exist? | Yes No |
| If YES, When do you usually suffer from it?: If NO, Please Skip to Question 5 | |
| Are you taking prescription medicine for this condition? | Yes No |
| If YES, Please list medications: If NO, Please Skip to Question 5 | |
| 5. *Do you wear contact lenses? | Yes No |
| 6. *Do you smoke? | Yes No |
| *Are you regularly in contact with other smokers | Yes No |
| PART II - Job Specifications | |
| 7.
*In which building is the issue occurring? *In which room # is the issue occurring? *In what area of the room is the issue occurring? | |
| 8. *What is your job title? | |
| 9. *During the course of the day are you in close proximity to computer terminals or photocopiers? | Yes No |
| If YES, What is the frequency of this contact? If NO, Please Skip to Question 10 | |
| 10. What other machinery or office equipment do you come in contact with? Please list equipment or enter "None" in the field provided. | |
| PART III - Environmental Situations Occurring Within the Facility -Please check all situations below you have experienced& describe where appropriate | |
| 11.
*Unusual Odors? If YES, please describe: | YesNo |
| 12.
*Uncomfortable Temperatures? If YES, please describe: | Yes No |
| 13. *Noticeable Dust in the Air? | Yes No |
| 14.
*Noises? If YES, please Describe: | Yes No |
| 15. *Mustiness or a Stuffy Feeling? | Yes No |
| 16. *Excessive Humidity or Dryness? | Yes No |
| 17. Other. Please Explain: | |
| 18. Are there any specific time frames when the above situations occur? | |
| Time Frame: | |
| *Certain Seasons? | Summer Spring Winter Fall Year Round |
| *Certain Days During the Week? | Monday Tuesday Wednesday Thursday Friday Saturday No |
| *Certain Times During the Day? | AM PM All Day Long No |
| *Certain Hours of the Day? Please List Hours or enter "No" in the field provided. | |
| Please provide any additional information regarding the Time Frames of the situation: | |
| PART IV - Symptoms or Health Reports | |
| 19. Please note below, in your own words, any symptoms or ailments that you have experienced on a recurring basis that you feel may be related to the building: | |
| 20. Do you notice any relation to the ailments you experience with the situations and time frames listed in section III? Please Explain Below or enter "No": | |
| 21. Which ailments or symptoms dissipate after leaving the facility? Please Explain Below or enter "None": | |
| 22. Which ailments or symptoms continue after leaving the facility and for how long? Please Explain Below or enter "None": | |
| 23. Are you aware or suspicious of anything that may be the cause of the environmental situations, symptoms or ailments described above? Please Specify What and Why Below or enter "No": | |