Preventative

Medicine 2
Occupational Health Model
Occupational History


Name: Date:
Age: Sex: Signature:
Job Title: Type of Industry: Contact No.
Name of Company:
Brief Job Description:
No. of hours of work/day/week:
No. of months or years in current job:

List of previous jobs, if any. Begin with the most recent.
Job Title and Description of
Date of Employment Exposures Protective Equipment
Work






COMMENTS or
Occupational Exposure Inventory Checklist YES NO
ADDITIONAL INFORMATION
1. Are you exposed to any of the following? List them:
Metal, dust or fibers, chemicals, fumes,
radiation, biologic agents, loud noise,
vibration, extreme heat or cold
2. Do you know the names of the metals,
dust or fiber, chemicals, fumes, radiation
that you were exposed to?
3. Do you get material on your skin or
clothing?
List PPEs:
4. Do you use PPEs?

5. Have you been instructed in the use of

PPEs?
6. Do any of your co-workers experience
similar or unusual symptoms?
7. Do your symptoms seem to be
aggravated by a specific activity?
8. Do your symptoms get either worse or
better at work? At home? On weekends?
On vacation?
9. Have you been off work for more than a
day because of an illness related to
work?
10. Have you ever been advised to change
jobs or work assignments because of any
health problems or injuries?

11. Has your work routine changed recently?

12. Is there poor ventilation in your
workplace?

13. Do you smoke in the workplace? At
home?