Att3 Chem Exp Question Bank 20130430

Att3 Chem Exp Question Bank 20130430.doc

ATSDR Exposure Investigations (EIs)

Att3 Chem Exp Question Bank 20130430

OMB: 0923-0048

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Attachment 3

Chemical Exposure Question Bank





Items from the question bank can be used to develop a survey for each submission.


Items marked with “*” are mandatory

[see http://minorityhealth.hhs.gov/templates/content.aspx?ID=9231&lvl=1&lvlID=10].

31 October 2011 - The Affordable Care Act requires new standards for the collection and reporting of health care information based on race, ethnicity, sex, and primary language. Making data standards consistent will help identify the significant health differences that often exist between and within ethnic groups. The new data collection requirements also will improve researchers' ability to consistently monitor more dimensions of health disparities among people with disabilities.


The use of all other items is not mandatory


All forms will display OMB Control Number, Expiration Date, and Public Reporting Burden

Example Script for Environmental and/or Biologic Sampling Events


Sample Introduction for Environmental Investigation:


Hello, my name is {SAY NAME}. We are doing an Exposure Investigation for the Agency for Toxic Substances and Disease Registry, or ATSDR. ATSDR is a sister agency to the Centers for Disease Control and Prevention. As part of the investigation, we will be asking you some common questions like your name and address. We will also ask questions about your contact with chemicals. We are asking these questions to better understand all the data we collect.



The questions should take less than thirty minutes. After that, we will be offering free {FILL IN TYPE(S)} = [FOR ENVIRONMENTAL-air, soil, water, foods testing] Once we are done with this investigation, you will be given a copy and details of -your location or the exposure location test results. Generally, we are able to get results to you within {FILL IN ADJUSTED TIME FRAME OR INSERT 4 – 8 WEEKS}.




Sample Introduction for Biologic Investigation:


Hello, my name is {SAY NAME}. We are doing an Exposure Investigation for the Agency for Toxic Substances and Disease Registry, or ATSDR. ATSDR is a sister agency to the Centers for Disease Control and Prevention. As part of the investigation, we will be asking you some common questions like your name and address. We will also ask questions on your contact with chemicals. We are asking these questions to better understand all the data we collect.



The questions should take less than thirty minutes. After that, we will be offering free {FILL IN TYPE(S)} = [FOR BIOLOGIC-blood, urine, hair, nails, other testing for all people who live in your home]. Once we are done with this investigation, you will be given a copy and details of -your and your minor children's (if you have them) test results]. Generally, we are able to get results to you within {FILL IN ADJUSTED TIME FRAME OR INSERT 4 – 8 WEEKS}.

Questionnaire Categories



General Information Questions

Example Script: Now I want to ask you questions about how I can contact you. I may also be asking how long you have lived at or visited certain places. This is needed to find out how long you may have had contact with chemicals and how long it may have lasted. We may also ask your age, race, weight and height, and about your jobs. This is useful to put your test results side by side with others like you to see what is typical.

NOTE: It is recommended that you ask the general questions last.

(Name of Survey Taker HERE :)


(Investigation ID)

(For ATSDR, use Cost Recovery Number plus auto generated 2 digit hyphenated add on)

(Participant ID Number)

(May need a drop down if participant has been in a previous investigation)

(Relationship/Household ID)

(Use some way to connect participants to a location, family name, etc. Choose by keying in one of the following or some other where a drop down list appears to connect people):

  • First Name/Last Name

  • Street and #, City, St

  • Exposure Location (Street. City, St or intersection)

  • Building

  • Room

(Laboratory ID)

(Given by lab. May be multiple if sample is split or divided into aliquots)

NOTE TO SURVEYOR: The following abbreviations and acronyms are used throughout.


DK-Don’t know

NA-Not applicable

Mm/dd/year-2 digit month, 2 digit day, 4 digit year

Ft-feet

In-inches

(First name of person answering questions for minor child)


(Last name of person answering questions for minor child)


General Information

First name:

(if minor child, put child’s name here)


Last name:


Middle Initial:


Street Address:


If this is an apartment, or the address has another defining number or letter, please provide that now:


City:


County:


State:


Zip Code:


Do you (or household head) rent or own this property?

Own

Rent

NA

If your mailing address is different from your street address, what is your mailing address?


City:


State:


Zip Code:


How long have you lived at this address?

Less than 6months

6mos to less than 2yrs

2 to5 yrs

6 to10 yrs

More than10 yrs


How long have you lived at this address?

(Note: use this question if you need a more exact date)

mm/year


How long have you lived in {Fill in Town, Neighborhood, or City of Interest}?

Less than 6 months

6mos to less than 2 yrs

2 to 5 yrs

6 to10 yrs

More than 10 yrs


Previous Address

Surveyor, ask for previous address if they have lived at current address less than a period you determine as a cut off. {6mos, 1 yr}.

What was your previous street address:


City:


State:


Zip Code:


Years at that address?


Please provide a phone number where we can reach you.

Home:

Work:

Cell:

Other:

Is there an email address where we can reach you? If yes, what is it?

No

Yes:



* How well do you speak English? (5 years old and older)

Very Well

Well

Not Well

Not at all

* Do you speak a language other than English at home? (5 years old and older)

Yes

No

* For persons speaking a language other than English (answering yes to the question above), what is the language? (5 years old and older)

Spanish

Other Language (Identify)

What is the occupation of the adults in the household?

(Note to surveyor: You may want to ask this question here or with the list of jobs in the confounder section but probably not in both sections)

Animal Control Worker, Animal Scientist, Veterinarian

Airport or Aircraft Worker

Arts & Media

Assemblers & Fabricator

Car Repair, Mechanic

Chemical Industry Worker (mixer, processor, researcher)

Child Care Worker

Cleaning homes or offices

Construction

Crop & Livestock Production

Dentist, Dental Hygienist

Detective and Criminal Investigator

Disabled & stay at home

Dry Cleaning Worker

Fire Fighter

Electrician, Electrical worker

Engineering, Sciences & Education

Equipment Operator

Etcher or Engraver

Extractive (e.g., mine machines, drills)

Explosives Worker

Farmworker

Fishing & Hunting

Floor Finisher

Food Processor

Food Service

Furniture Finisher

Grounds Maintenance Worker

Hairdresser, Hair Stylist &/or Cosmetologist

Health Care Worker

Home Care Taker

Installation, Maintenance & Repair Worker

Jeweler

Logging, Forest & Conservation Worker

Machinist

Material Moving

Metalworking & Plasticworking

Miner

Miscellaneous Production Worker

Manicurist

Mortician and Embalmer

Office Worker

Painter

Pest Control Worker

Petroleum worker

Photo processing, photographer

Physician, Anesthesiologists

Pilot

Police or Sheriff Patrol Officer

Printing Worker

Retired

Roofer

Textile, Apparel & Furnishing Worker

Utilities & Transportation Worker

Welder including soldering & brazing

Woodworker

Other: List: ____________________________

None


Demographic Questions

Script: The next questions are about your own qualities and will help us compare your test results.


Surveyor, please indicate whether the person is a male or female. If this questionnaire is for a minor child, be sure to ask their gender.

* What is your sex?

M

F

Date of Birth: dd/mm/yr(xxxx)


* Are you Hispanic, Latino/a, or Spanish origin?

(One or more categories may be selected)

No, not of Hispanic, Latino/a, or Spanish origin

Yes, Mexican, Mexican American, Chicano/a

Yes, Puerto Rican

Yes, Cuban

Yes, Another Hispanic, Latino, or Spanish origin

* What is your race??

(One or more categories may be selected)

White

Black or African American

American Indian or Alaskan Native

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian


Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander

What is your current height?

Ft

in

What is your current weight?

lbs

(If female) Are you pregnant? If yes, in what month of pregnancy?

No

Yes: 0-3 4-6 7-9

* Are you deaf or do you have serious difficulty hearing?

Yes

No

* Are you blind or do you have any serious difficulty seeing, even when wearing glasses?

Yes

No

* Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? (5 years old and older)

Yes

No

* Do you have serious difficulty walking or climbing stairs? (5 years old and older)

Yes

No

* Do you have difficulty dressing or bathing? (5 years old and older)

Yes

No

* Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? (15 years old and older)

Yes

No

Household Characteristics

Script: The next set of questions is about the number of people in the household and how long you have lived here.


How many people live here fulltime since (INSERT TIMEFRAME), including yourself?

(# People in Household)


Are there any children under the age of 18 who live in the household? [if NO skip the next questions]

Yes

No

How many children are between the ages of 0-6 years old?


How many children are between the ages of 7-12 years old?


How many children are between the ages of 13-18 years old?


Do they play or ride bikes in bare soil?

Never Do This

Seldom Do This

Sometime Do This

Always Do This

If there are children who regularly (Choose a timeframe: daily/weekly) visit the household, what are the ages of children under 18?


Please estimate to the nearest hour approximately how long each person was present in the home in the last (INSERT TIMEFRAME).

Person 1

Person 2

Person 3

Person 4

Person 5

Person 6


Exposure Location

Note to Surveyor: If the potential exposure location is different than the household address, ask the following questions. Also fill in the exposure location by address, long/lat, or some other way.

Did the potential exposure take place away from home?

Yes

No

If yes, where? (Building Name)


(Room Number)


(Exposure Location- Street Address)


(Street Address 2 for intersections)


(City)


(State)


(Zip Code)


How long have you been visiting or going to the (Fill in Location Name)?

mm/year

When was the last time you were at the (Fill in Location Name)?

mm/dd/year

What do you do or were you doing at the (Fill in Location Name) exposure location (for example, work, hunt or fish, etc.)?


Exposure Location Information from ATSDR’s Rapid Response Registry

At the time of the event on [specify day and time], what address were you [was the registrant] at or what was the name of the building or intersection closest to you [the registrant]?


Were you [was the registrant] present at [the event site]?

Yes

No

DK

Refused

If yes, were you [was the registrant]:

inside a building or structure

inside a car or other vehicle

Outside

Other

Specify:

Don’t Know (DK)

Refused



Did you [the registrant] get an injury or any illness as a result of the event?

Yes

No

DK

Refused

If Yes, what illness or injury did you [the registrant] get? (List all)


DK

Refused

Before the event, did you [the registrant] have a:

Chronic illness

Physical Disability

Other Disability

Unsure

Refused


Are you [is the registrant] pregnant? [or "Were you (was the registrant) pregnant at the time of the event?"]

Yes

No

DK

Refused

Are you [is the registrant] in need of:

Medications/ supplies

Medical care

Utilities

Food

Shelter

DK

Refused





Indoor Air

Script: These questions will help us determine the possible sources of air pollutants in your household and any symptoms or conditions that would make breathing pollutants more harmful to you.

Time Indoors

How many hours per day do you spend inside your home in a usual weekday? (24 hours is one day)

Less than 8 hours

Between 8 and 14 hours

Between 15 and 24 hours


How many hours per day do you spend inside your home in a usual weekend? (24 hours is one day)

Less than 8 hours

Between 8 and 14 hours

Between 15 and 24 hours


How many fewer hours do you spend indoors during the warmer months? (How much additional time are you outside)?

Same

Between 1 and 3 more hours

4 or more hours

How many hours per day did you spend inside the home [INSERT TIMFRAME]? (24 hours is one day)


How many hours per day did you spend away from home [INSERT TIMFRAME]? (24 hours is one day)?


Did you leave you window open [add timeframe]?


Confounders and Other Sources

Script: These questions relate to other things that may trigger symptoms similar to air pollutants.


Note to surveyor: Confounders to symptoms are listed here. Chemical specific confounders are listed under the chemical you are investigating.


Are there any smokers in the household (not including you) [if ‘no’ skip]?

Yes

No

Do you currently smoke?

Yes

No

Refused

If you smoke, how long ago did you smoke your last cigarette?


[If there are any smokers in the house] How many people smoke?


How many cigarettes per day are usually smoked anywhere inside the home by anyone? (20 in a pack)

none

1-5

6-10

11-20

>20

How many cigars per day are usually smoked anywhere inside the home by anyone?

None

1

>1

In the last three days, did {you/she/he} spend 10 or more minutes near a person who was smoking a cigarette, cigar, or pipe?

Yes

No

DK

How many pipes per day are usually smoked anywhere inside the home by anyone?

None

1

>1

Do you have any pets?

Yes

No

What types of indoor pets do you have in your home?

Dog

Cat

Rodents: hamster, mice, rat, gerbil, guinea pig

Rabbit

Ferret

Other: list

Fuels Used Indoors


Do you use any of the following in your home?

Natural gas used for heating

Natural gas used for cooking

Propane gas used for heating

Propane gas used for cooking

Kerosene

Coal used for heating

Coal used for cooking

Wood Burning Stove used for heating

Wood Burning Fireplace used for heating

Wood Burning Fireplace used for cooking

Gasoline

Solar

Artificial Logs (disposable store bought e.g., Duraflame)

None

If ‘none’ skip next two questions.

During which month do you (or does the building) usually start using those fuels?

Start Month: Jan Feb March April May June July August Sept Oct Nov Dec

During which month do you usually (or the building) stop using those fuels?

Stop Month: Jan Feb March April May June July August Sept Oct Nov Dec


Symptoms/Conditions


Script: Individuals with certain conditions may be more sensitive to the effects of chemicals. I would like to ask you questions about your health.

Is anyone in the household pregnant?

Yes

No

DK

If yes, in what month of pregnancy?

0-3

4-6

7-9

Adults

Have you or any other adult household members ever been told by a health care professional that you/they have a chronic heart or lung conditions, such as coronary artery disease, angina (pain in the heart), asthma, or emphysema? [if ‘no’ go to the next section]

Yes

No

Refused

Do you/they currently have that condition?

Yes

No

Don’t Know

If yes, please describe the health condition(s).


Are there any adults with chronic heart or lung conditions, such as coronary artery disease, asthma or emphysema?

No

Yes

DK

Are there times when your condition(s) gets worse? (e.g., night, day weekend, weekday)

Yes

When?

No

Are there any places when your condition(s) get worse? (e.g., home, work, school)

Yes

When?

No

Are there any seasons when your condition(s) get worse? (e.g., spring, summer, fall, winter)

Yes

When?

No

Children

Are there any children (under the age of 18 years old) with chronic heart or lung conditions, such as congenital heart disease, asthma or cystic fibrosis?

Yes

No

Don’t Know

If yes, what are the ages of these children?


Please describe the condition(s).


Are there times when your condition(s) gets worse? (e.g., night, day weekend, weekday)

Yes

When?

No

Are there any places when your condition(s) get worse? (e.g., home, work, school)

Yes

When?

No

Are there any seasons when your condition(s) get worse? (e.g., spring, summer, fall, winter)

Yes

When?

No

Odors/Fumes

Have you or your household members of any age noticed odors or fumes in your home or in common areas where you spend the most time (bedroom, living room, kitchen)?

Yes

No

DK

If yes, please describe the odors/fumes, as well as their location, when they occur (times of the day, days of the week, seasons of the year), and duration:

Describe odor:

When:

Time of day

Day of week

Season

How long:




Have you been told you have the following:


Condition

Yes/No

Were you told you had this by a doctor or nurse? Yes/No

How old were you when a doctor or nurse first told you?

Asthma, allergies




Chronic bronchitis or emphysema?




Angina







Attributes of the Structure or Home

The following questions are about the qualities and characteristics of your home.


Do you live in an:

Apartment

Single Family Home

Townhouse or Condominium

Mobile Home

Other (Specify)

If you live in an apartment, town home, or any multistory structure, how many floors are there?

Number of floors in building _____

If you live in an apartment, town home, or any multistory structure, what floor do you live on?

Participant floor number _____

About when was the building built?

2000-present

1990-1999

1985-1989

1980-1984

1970-1979

1960-1969

1950-1959

1940-1949

1939 or earlier

DK

What is the condition of your home or building?

Good

Fair

Poor

Is the home or building built on a slab?

Yes

No

DK

Does the home or building have a basement?

Yes

No

DK

Does the home or building have a crawlspace?

Yes

No

DK

Does the home or building have an attached garage?

Yes

No

DK

Do the windows (e.g., sills) have peeling paint?

Yes

No

DK

Is there peeling paint in other places?

Yes

No

DK

Do you currently have mold in your home on an area greater than the size of a dollar bill?

Yes

No

DK

Refused

Do you have a woodstove or fireplace?

Yes

No

Does smoke enter the room when you use it?

No

Yes

DK

Are there any chemicals or open containers stored in or near the living spaces of your home?

Yes

No

DK

Do you use pesticides in your home?

Yes

No

DK

Other

Is there anything you want us to know that we did not ask about?




Water

Script: These questions will help us determine the overall quality of your water as it relates to your exposure or use.

What is your main source of drinking water in your home or building?


City or county (public)

Private well

Spring

Pond

Cistern

Community well

Bottled

Other Specify: __________

Don’t know


(If a water company) What is the name of the water company that provided the water (the place where you send in your water bill)?

(Interviewer may want to get the usage off the water bill)


If you have a private well, has it been tested?

Yes

No

DK

If ‘yes’ do you know the date it was tested, who did the testing, whether it was tested for bacterial and/or chemical contamination, and the results?

Date:

Company:

Bacteria / Chemical


Results:

What is your main source of water used for cooking?


City or county (public)

Private well

Spring

Pond

Cistern

Community well

Bottled

Other Specify: ____________

Don’t know


What is your main source of water for bathing and showering?

City or county

Private well

Spring

Pond

Cistern

Community well

Bottled

Other Specify: ______________

Don’t know


Surveyor, the next three questions are for suspect Volatile Organic Compounds (VOCs) in water:

In the last three days [or INSERT TIMEFRAME], did {you/she/he} take a hot shower or bath for five minutes or longer?

Yes

No

DK

How long ago, in hours, has it been since {your/her/his} last shower or hot bath?


Do you limit time showering and bathing?

Never

Sometimes

Always

Do you shower or bathe in cool water?

Never

Sometimes

Always

Do you limit steam exposure (e.g., from dishwasher, boiling)?

Never

Sometimes

Always

What is your main source of water for pools and hot tubs?

City or county

Private well

Spring

Pond

Cistern

Community well

Bottled

Other Specify: ______________

Don’t know


List all of the water treatment devices for your drinking water or water used for mixing drinks (e.g., formula, juices).

None

Charcoal Filter/Granular Activated Carbon (GAC)

Ceramic Filter

Reverse Osmosis

Water Softener

Boil Water

Distillation

Aerator

Water Filter System (Brita, Pur, etc)

List all of the water treatment devices for your water used for cooking.

None

Charcoal Filter/GAC

Ceramic Filter

Reverse Osmosis

Water Softener

Boil Water

Distillation

Aerator

Water Filter System (Brita, Pur, etc)

List all of the water treatment devices for your bathing and showering water.

None

Charcoal Filter/GAC

Ceramic Filter

Reverse Osmosis

Water Softener

Boil Water

Distillation

Aerator

Water Filter System (Brita, Pur, etc)

Do you use water filters in your home?

Yes

No

DK

If you have filters, do you regularly replace and maintain filters?

Never

Sometimes

Always

DK

Do you follow drinking water recommendations?

Never

Sometimes

Always

DK

Plumbing

Do you have copper pipes?

Yes

No

DK

Does your plumbing have lead solder?

Yes

No

DK



Soils


Script - If chemicals are in the soils, you can get them on your skin by gardening, playing, touching your pets, walking barefoot on exposed dirt (no grass, mulch, etc).


If the question is not applicable to you , please answer "Never Do This."

Soils Information –Contact

Did you bring home [LIST soil, products, etc] from [LIST LOCATION].

Yes

No

How often do you work in soil IN YOUR YARD (e.g., gardening, digging, building, repairing)?

Never Do This

Seldom Do This

Sometimes Do This

Always Do This

If "Never Do This", skip next 5 questions

If so, how frequently do you work in soil in your yard?

Daily

Weekly

Monthly

How often do you use gloves and protective clothing when you work in soil? (e.g. working, playing outdoors, gardening, yardwork)

Never Do This

Seldom Do This

Sometimes Do This

Always Do This

How often do you change clothes immediately after outdoor activity (e.g. working, playing outdoors, gardening, yard work)

Never Do This

Seldom Do This

Sometimes Do This

Always Do This

How often do you wash hands, face, and/ or other exposed skin immediately after outdoor activity (e.g., working, playing outdoors, gardening, yard work)?

Never Do This

Seldom Do This

Sometimes Do This

Always Do This

How often do you wash dirty clothes immediately after wear (e.g., work clothes, yard work clothes)?

Never Do This

Seldom Do This

Sometimes Do This

Always Do This

Soil Information (Tracking inside home)

How often do you remove shoes before entering your home?

Never Do This

Seldom Do This

Sometimes Do This

Always Do This

How often do you cover bare soils with turf or mulch?

Never Do This

Seldom Do This

Sometimes Do This

Always Do This

How often do you wet-down disturbed soils (e.g. gardening, digging, building)?

Never Do This

Seldom Do This

Sometimes Do This

Always Do This

When you go outside, how often do you have contact with dirt without shoes?

Never Do This

Seldom Do This

Sometimes Do This

Always Do This

Pets (Tracking dirt inside and dander)

Do you have any pets?

Yes

No

What types of indoor pets do you have in your home?

Dog

Cat

Rodents: (hamster, mice, rat, gerbil, guinea pig)

Rabbit

Ferret

Other:

When your pets go outdoors, how often do they track dirt into the house?

Never Do This

Seldom Do This

Sometimes Do This

Always Do This

List the number of indoor pets that regularly go outdoors.


Note to surveyor - The pets questions can be asked of one person in the household and don't have to be repeated for each person.

House Cleaning Frequency

Script –This next set of questions is about the cleaning habits in your home by you or someone else.

Note to surveyor: The home cleaning questions can be asked of one person in the household and don't have to be repeated for each person.

How often does anyone wet mop your home?

Twice a week

Once a week

Less than once a month

Never

How often does anyone dry dust your home?

Twice a week

Once a week

Less than once a month

Never

How often does anyone broom sweep your home?

Twice a week

Once a week

Less than once a month

Never

How often does anyone vacuum your home? [if never go to next section]

Twice a week

Once a week

Less than once a month

Never

Does your vacuum have a bag?

Yes

No

Does your vacuum have a high efficiency particulate air (HEPA) filter?

Yes

No

Don’t Know

Was (INSERT TYPE OF CLEANING, OR SAY ANY CLEANING) done in rooms where the samplers were placed?

Yes

No

If yes, what type of cleaning?

Vacuum

Damp mop

Wet mop

Dry mop or dust

Sweep

Other:

If you currently have children ≤ 18 in your home, please respond to the following statements. If not, please skip to the next section.

Do you keep children from playing, biking, or doing other activities in areas with possible soil contamination?

Never Do This

Seldom Do This

Sometimes Do This

Always Do This

Do you keep children from eating dirt?

Never Do This

Seldom Do This

Sometimes Do This

Always Do This

Do you keep children from putting their fingers and hands in their mouths?

Never Do This

Seldom Do This

Sometimes Do This

Always Do This



Garden

Script: The next questions are about your contact with fresh fruits and /or vegetables

Does anyone, including you or a lawn service, use chemicals on your lawn or garden?

Yes

No

Don’t know

Do you or your neighbor grow fruits and vegetables in the yard?


Yes

No

What vegetables/fruits do you grow and eat from you or your neighbor’s garden?


When was the last time you ate that vegetable and/or fruit?

Days

Weeks

Months

Years ago

When you eat those fruits and/or vegetables, how often do you eat them?

Daily

Weekly

Monthly

How often do you wash the vegetables and/or fruit before you eat them?

Never

Sometimes

Always

How often do you wash the vegetables and /or fruit before you cook them?

Never

Sometimes

Always

(Note to surveyor: Process can include pressure cooking (can or bag, hot water (can or bag), freezing, or drying)

Do you process your fruit and vegetables or your neighbor’s? [if 'no' go to next section]

Yes

No

Don’t Know

When was the last time you ate your processed fruit or vegetables?

Days

Weeks

Months

How often do you or your family eat the vegetables and/or fruit you processed from your garden?

Daily

Weekly

Monthly

How often do you or your family eat the vegetables and/or fruit you processed from your neighbor’s garden?

Daily

Weekly

Monthly



Foods


Fish

Script: These questions will help us determine if eating locally caught fish may increase your contact with chemicals.


First for the following questions, when I say “fish”, I mean any type of seafood, including shellfish, squid, crab, sea urchins or seaweed

Does anyone in your household currently catch fish (of any kind) from [LIST WATERBODY]?

Yes

No

DK

Does anyone in your household eat the fish caught from [LIST WATERBODY]?

Yes

No

DK

How long have you eaten fish?

(RECORD IN YEARS)


Script: When I say “fish meals”, I mean any meal you had which consisted of the entire fish or parts of fish

What kind of fish and how many fish meals have you eaten in [INSERT TIME FRAME OR USE the last 30 days]?

(RECORD NUMBER for each)


How many ounces of fish do you usually eat in one meal?


(Surveyor: USE A MODEL FOR SIZE IF POSSIBLE)

1-4oz

5-8oz

>8oz

What is your primary source of fish? In other words, where do you usually get the fish that you eat? Do you… (SURVEYOR: READ LIST. ONE ANSWER ONLY)

Catch fish yourself or get it from a household member

Purchase from a roadside vendor or flea market

Purchase from a fisherman’s co-op

Purchase from a supermarket

Purchase from a restaurant

Receive from family and friends

Other (SPECIFY

In the last 30 days, how often did you eat fish caught from LIST WATERBODY(IES) OF INTEREST?


For (AREAS MENTIONED ABOVE), what type(s) of fish did you USUALLY catch, take home and eat?


Did you eat fish within the last [INSERT TIME FRAME OR USE seven days]?

Yes

No

Where did you get the fish that you ate within the last [INSERT TIME FRAME OR USE seven days]? In other words, where do you usually get the fish that you eat? Do you… (READ, CIRCLE ALL THAT APPLY)

Catch fish yourself or get it from a household member

Purchase from a roadside vendor or flea market

Purchase from a fisherman’s co-op

Purchase from a supermarket

Purchase from a restaurant

Receive from family and friends

Other (SPECIFY)

(FOR EACH FISH EATEN) Which parts of this fish do you usually eat? (CHECK ALL THAT APPLY)

Whole Filet Head Bones Intestines

Eyes Skin Fish eggs (roe)


FOR EACH FISH EATEN) How do you usually prepare this fish? Do you skin it, trim the fat, gut it, a combination of, or some other way?

Skinning Trimming fat Gutting Combination Other


What is your PRIMARY cooking method for this fish?

Raw Pan Fried Deep Fried Boiled/

Stewed Grilled Baked Other


Communication/Education


Before taking this survey, were you aware of the LIST ADVISORY that has been issued for the LIST AREA?

Yes

No


Which of these information sources made you aware of the ADVISORY OR WARNING?

(CHECK ALL THAT APPLY)


    • A story in the newspaper

    • A print advertisement in the newspaper

    • Television broadcast

    • Radio talk show or radio news

    • Posted signs and notices

    • Meeting

    • Family and friends

    • Church announcement/church bulletin or newspaper

    • Word of mouth

    • Other


Since you learned about the ADVISORY OR WARNING, have you made any changes in either the way you eat the fish you catch or in your fishing habits?

No, I have not made any changes in my fishing or eating habits.

Yes

If ‘yes’, which of these apply to you?

    • I no longer eat any fish from the Advisory or Warning area

    • I eat less fish now than before the Advisory or Warning.

    • I eat more fish now because I can choose fish from areas outside the Advisory or Warning area.

    • I have reduced the size of my fish meal portions.

    • I have changed the way I prepare locally caught fish before I eat it.

    • I have changed the way I cook locally caught fish before I eat it.

    • I have changed my fishing locations.

    • I have changed the species I fish for because of the Advisory or Warning.

    • Other

How would you like to be informed of any future advisories or notices?

    • Newspaper article

    • Newspaper advertisement

    • Television news broadcast

    • Radio talk shows/news

    • Posted signs and notices in areas that you fish

    • Meetings

    • Family and friends

    • Church announcement/church newspaper

    • Word of mouth

    • Other



Domestic Animals

Script: These questions will help us determine if eating locally raised domestic animals may increase your contact with chemicals.


First for the following questions, domestic animals are defined as locally raised animals that are used as a source of meat (such as cattle or chicken). Also the products of these domesticated animals such as milk or eggs are to be included in this survey

Do you currently eat locally raised domestic animals (of any kind)?

Yes

No

If yes, what type and how are they used for food?

Domestic Food # meals Source

Animal in last 30 (see list)

days

_____________________________________________________

Cattle: Beef Milk* **Organs

Chicken: Meat Eggs Organs

Goat: Meat Milk* Organs

Sheep/Lamb: Meat Milk* Organs

Pigs/Boar: Meat Organs

Turkey: Meat Eggs Organs

Ostrich: Meat Eggs Organs

Other: List


* Milk and milk products including milk, butter, cheese, yogurt, etc)

**Indicate if the milk products are pasteurized.


Source List:

Where do you usually get the domestic animals that you eat? Do you… (READ LIST. ONE ANSWER ONLY)


  1. Raise domestic animals yourself or get it from a household member

  2. Purchase from a roadside vendor or flea market

  3. Purchase from a domestic animal co-op

  4. Purchase from a supermarket

  5. Purchase from a restaurant

  6. Receive from family and friends

7. Other (SPECIFY)

Game

Script: Game refers to wild animals such as deer which are hunted and used as a source of food.

Do you currently eat game (of any kind)?

No, NEVER

I do not currently eat game, nor have I ever eaten game.

No, PREVIOUS but I have previously eaten game.

Yes

How long have you eaten game?

(RECORD IN YEARS)


Do you hunt or is game given to you to eat?

Yes

No

Where do you hunt? (RECORD LOCATION)



Check the game you consume and list how often (weekly, monthly, yearly) and the primary place you get the game (READ LIST. ONE ANSWER ONLY):

Game Frequency Source

(Weekly, Monthly, Yearly) (see list)

____________________________________________

Deer

Rabbit

Quail

Duck

Dove

Turkeys

Elk

Caribou

Alligator

Other: List


Where do you usually get the game that you eat? Do you…

  1. Hunt game yourself or get it from a household member

  2. Purchase from a roadside vendor or flea market

  3. Purchase from a game co-op

  4. Purchase from a supermarket

  5. Purchase from a restaurant

  6. Receive from family and friends

  7. Other (SPECIFY)



Confounders/Other Possible Sources of Exposure Questions

Script: For the next set of questions, we will be asking you about other ways or places you may have come in contact with chemicals.

Occupational Questions

Script: Answer the following questions about the kinds of jobs you have had.

What is the name of your current employer (s)?

Job1

Job2

Job3

Which best describes your current employment status?

Employed for wages

Self-employed

Out of work for more than 1 year

Out of work for less than 1 year

A Homemaker

A Student

Retired

Unable to Work

At your present work:




What best describes the type of work you are doing (at Job 1, Job2, Job3 etc.)?



(Note to surveyor: This is an example of an industry or occupation list. It should be edited to only include jobs of interest to your investigation (e.g., jobs that may include chemical use similar to what you are investigating. If you want to include an exhaustive list of occupations or industries, you can use the U.S. Census list found at http://www.census.gov/hhes/www/ioindex/overview.html


If you want to narrow the list to jobs or industries with chemical of interest, consider searching “agents” @ http://hazmap.nlm.nih.gov/, then look at processes, industries, and activities with risk of exposure. You can also search it backward when you know a job and it will tell you the hazards associated with that job.)


Animal Control Worker, Animal Scientist, Veterinarian

Airport or Aircraft Worker

Arts & Media

Assemblers & Fabricator

Car Repair, Mechanic

Chemical Industry Worker (mixer, processor, researcher)

Child Care Worker

Cleaning homes or offices

Construction

Crop & Livestock Production

Dentist, Dental Hygienist

Detective and Criminal Investigator

Disabled & stay at home

Dry Cleaning Worker

Fire Fighter

Electrician, Electrical worker

Engineering, Sciences & Education

Equipment Operator

Etcher or Engraver

Extractive (e.g., mine machines, drills)

Explosives Worker

Farmworker

Fishing & Hunting

Floor Finisher

Food Processor

Food Service

Furniture Finisher

Grounds Maintenance Worker

Hairdresser, Hair Stylist &/or Cosmetologist

Health Care Worker

Home Care Taker

Installation, Maintenance & Repair Worker

Jeweler

Logging, Forest & Conservation Worker

Machinist

Material Moving

Metalworking & Plasticworking

Miner

Miscellaneous Production Worker

Manicurist

Mortician and Embalmer

Office Worker

Painter

Pest Control Worker

Petroleum worker

Photo processing, photographer

Physician, Anesthesiologists

Pilot

Police or Sheriff Patrol Officer

Printing Worker

Retired

Roofer

Textile, Apparel & Furnishing Worker

Utilities & Transportation Worker

Welder including soldering & brazing

Woodworker

Other: List: ____________________________

None

What is your current job title?

Job1

Job2

Job3

What are your main job tasks?

Job1

Job2

Job3

When did you start to work for your current employer(s)?

(Note: try to get month and year or at least year) or

current job” )

mm/dd/year



For the following questions, “contact” means touching, breathing, or eating/ ingesting/swallowing

Do you have contact with harmful chemicals, physical debris, dusts or mists, or hazardous powders at your current job?

Yes

Job1

Job2

Job3

No

DK

If yes to the above question, please describe the hazard

(Surveyor, list the hazards and circle the response).

Solvents

Breathing

Physical

Dusts

Fuels

Breathing

Touching

Gas

Touching

Swallowing

Liquid

Swallowing

Other (list)

Mists

Other (list)

Asbestos

Silica

Lead

Have you or could you have contact with radiation at your job?

Yes

Describe:

No

DK

Have you or could you have contact with [INSERT CHEMICAL OR COMPOUNDS OF INTEREST] at your job (e.g., lead, asbestos, silica)?

Yes

Job1

Job2

Job3

Describe:

No

DK

Are you required to wear protective equipment at your current job? [if ‘no’ skip to the next section]

Yes

No

Do you wear protective equipment such as gloves, dust mask or respirator, hood, etc at work?

Always

Sometimes

Never

What type of equipment was worn?

Gloves


Always


Dust Mask

Always

Respirator

Always

Sometime


Sometime

Sometime

Never

Never

Never

Coverall/

Clothing

Always

Eye Protection

Always

Hood

Always

Sometime

Sometime

Sometime

Never

Never

Never

Do you wear your work clothes home?

Always

Sometimes

Never

Do you wear your work shoes home?

Always

Sometimes

Never

Do you shower and/or change clothes before coming home from work?


Always

Sometimes

Never

Have you ever been off work from your current job for more than a day because of an illness or injury related to your work?

Yes

Describe:

When:

No


At your past work:


What jobs or industries have you worked in the past (Surveyor: insert 1, 2, 5, 10 or other timeframe of interest) year(s)?


Note when (approximate year or timeframe) and approximately how long (months or years) by each.


Example: Welding and soldering metals, 1989-

Construction, 1987, years

Job

Time Period

Months

Years



Months

Years



Months

Years

What is the longest job held? When? How long?




Have you ever been in the military?

Yes

Main Job Tasks:

When:

How long:

No

Have you ever worked on a farm or done seasonal farm work?

Yes

Main Job Tasks:

Describe:

When:

How long:

No

At your past work, have you ever worked at a facility that [INSERT (processed, machined, used)] [INSERT CHEMICAL OR COMPOUND]?

Yes

Job Tasks:

Describe:

Job Title:

When:

How Long:

or

Year Began:

Year End:

No

Have you ever been off work from a past job for more than a day because of an illness or injury related to your work?

Yes

Describe:

When:

No

Have you ever changed jobs or work assignments because of work-related health problems or injuries?

Yes

Describe:

When:

No

Occupational/Take Home Questions

Script: Answer the following questions about the jobs people in or visiting the household have had.

Has anyone in the household worked in [list industry]?


Surveyor: If more than one person has contact with chemicals, ask these questions for each separately.

Yes

No

Did that person come home from work without showering?

Always

Sometimes

Never

DK

If they worked in the past: Did that person wear work clothing home after working?

Always

Sometimes

Never

DK

Did that person wear protective equipment such as gloves, dust mask or respirator, hood, etc at work?

Always

Sometimes

Never

DK

Did they wear their work shoes home?

Always

Sometimes

Never

DK

If they are currently working: Does that person wear work clothing home after working?

Always

Sometimes

Never

DK

Do they wear their work shoes home?

Always

Sometimes

Never

DK

Does that person shower before they come home from work?

Always

Sometimes

Never

DK

Does that person wear protective equipment such as gloves, masks, hood, etc at work?

Always

Sometimes

Never

DK


Hobbies Questions

Script: A hobby is considered an activity or interest pursued outside one’s regular occupation and engaged in primarily for enjoyment. Answer the following questions about your hobbies and activities at home.

What hobbies do you or your household members engage in AT home?


(List hobbies (excluding sports). Example: woodworking, stained glass, etc.)


(Note to surveyor: If you want to narrow the list to hobbies with chemical of interest, consider searching the tab “ingredients” @ http://hpd.nlm.nih.gov/index.htm , then list the chemical and it will provide a list of products that contain it. You can also search “products” and choose “arts and crafts” to display the chemicals associated with the hobby.)


Batik printing

Candle-making

Ceramics making

Dye Use

Electronics

Epoxy Use

Enameling

Fishing gear (making) sinkers, etc

Glassblowing

Home remodeling

Intalagio printing

Jewelry making

Leather crafting

Lithography printing

Lost wax casting

Metal work

Model making

Painting

Preparing, stuffing, and mounting animal skins (taxidermy)

Soap making

Staining

Sculpturing plastics

Sculpturing stone containing crystalline silica, e.g., granite

Stained glass making

Woodworking

None

What hobbies do you or your household members engage in AWAY from home?


(List hobbies (excluding sports). Example: woodworking, stained glass, etc.)


Batik printing

Candle-making

Ceramics making

Dye Use

Electronics

Epoxy Use

Enameling

Fishing gear (making) sinkers, etc

Glassblowing

Home remodeling

Intalagio printing

Jewelry making

Leather crafting

Lithography printing

Lost wax casting

Metal work

Model making

Painting

Preparing, stuffing, and mounting animal skins (taxidermy)

Soap making

Staining

Sculpturing plastics

Sculpturing stone containing crystalline silica, e.g., granite

Stained glass making

Woodworking

None

Do you burn, solder, or melt any products?


Yes

No

If yes, please describe:


On average, for the past month, how many days did you use lead solder to join pieces of stained glass?


    • Never

    • 1-3 days per month

    • 1-2 days per week

    • 3-6 days per week

    • Daily

    • Don’t know


On average, for the past month, how many days did you use lead based oil paint to paint pictures or jewelry?

  • Never

  • 1-3 days per month

  • 1-2 days per week

  • 3-6 days per week

  • Daily

  • Don’t know


Do you use any alternative healing or cultural practices?


Yes

Describe:

No


Household Chemical Uses and House Construction Questions


Script: To the best of your ability, answer the following questions about the household products you are using and/or that were used in the construction of your home.

Fuels

Have you recently (within the past {X} days) used or been near fuels?

Yes

No

Is any gasoline, diesel, fuel oils, or kerosene being stored in any room or basement of your home or in an attached garage or carport?

Yes

No

Are any devices with gasoline or diesel engines such as lawn mowers being stored in any room or basement of your home or in an attached garage or carport?

Yes

No

In the last three days – today, yesterday, or the day before yesterday


In the last three days [or INSERT TIMEFRAME], did {you/she/he} pump gas into a car or another gasoline/diesel powered engine {yourself/herself/himself}?

Yes

No

How long ago, in hours, did {you/she/he} pump gas?


When did you last ride in a gasoline/diesel powered vehicle?


In the past three days [or INSERT TIMEFRAME], have you breathed fumes from car, lawn mower or any other gasoline or diesel powered engine?

Yes

No

How long ago, in hours, did {you/she/he} breathe fumes?


Landscape or Yard Products

Have you recently (within the last {X} days or weeks) used any landscape or yard products such as fertilizer, lawn care, swimming pool products, etc?

Yes

No

If so, list the commercial or brand name of those


Cleaning Products

Have you recently (within the last{ X} days or weeks) used any cleaning products inside the home? Example: air fresheners, bleach, toilet bowl cleaner, etc

Yes

No

If so, list the commercial or brand name of those.



Yesterday or {INSERT TIMEFRAME}, did any activities in the home or elsewhere involve working with or being near stain or spot removers?

Yes

No

If so, list the commercial or brand name of those.



Auto Products

Have you recently (within the last{ X } days or weeks) used any auto products such as brake fluid, de-icer, lubricant, sealant, etc?

Yes

No

If so, list the commercial or brand name of those.



Home Maintenance and Renovations

Have you recently (within the last {X} days or weeks) used any home maintenance products such as caulk, grout, insulation, paint, putty stain, etc?

Yes

No

If so, list the commercial or brand name of those.



Are any paints or varnishes being stored in any room or basement or your home or in an attached garage or carport?

Yes

No

Are any woodworking solvents, paint stripping fluids or adhesives stored in any room or basement of your home or in an attached garage, or carport?


Yes

No

On average, for the past month, how many days did you paint walls, furniture, cars, or other objects?

  • Never

  • 1-3 days per month

  • 1-2 days per week

  • 3-6 days per week

  • Daily

  • Don’t know


On average, for the past month, how many days did you use chemical paint strippers?


    • Never

    • 1-3 days per month

    • 1-2 days per week

    • 3-6 days per week

    • Daily

    • Don’t know


On average, for the past month, how many days did you remove paint by other methods such as scraping, heat gun, or sanding?


  • Never

  • 1-3 days per month

  • 1-2 days per week

  • 3-6 days per week

  • Daily

  • Don’t know

In the {last 6 months or INSERT TIMEFRAME}, have you or anyone else renovated your home in any way? This would include indoor painting, refinishing floors, adding rooms to the house or laying new carpet.

Yes

No

In the{last 6 months or INSERT TIMEFRAME}, was any indoor painting done?


Yes

No

In the{last 6 months or INSERT TIMEFRAME}, have the floors in your home been refinished?

Yes

No

In the{last 6 months or INSERT TIMEFRAME}, have you had new carpet installed?

Yes

No

If you have had new carpet, was glue used or was it tacked down?

Glue

Tacked

Other

DK

In the{last 6 months or INSERT TIMEFRAME}, were additions constructed to the house or building?

Yes

No

Pesticides, Herbicides

Have you recently (within the last {X} days or weeks) used any pesticides including animal repellant, fungicide, herbicide, insecticide, etc to get rid of insects, rodents or other pests?

Yes

No

Was that done:

Inside

Outside

Both

If so, list the commercial or brand name of those




How many times in the (insert time period) were pesticides applied by a PROFESSIONAL?


1-2

3-5

6-9

10+

How many times in the last (insert time period) did you PERSONALLY apply pesticides?


1-2

3-5

6-9

10+

In the past month, were any chemicals used to treat this home to control fleas, roaches, ants, termites, or other insects?

Yes

No

DK

Pet Products

Have you recently (within the last {X} days or weeks) used any pet care products such as flea & tick control, litter/stain/odor remover?

Yes

No

If so, list the commercial or brand name of those.



Arts and Crafts

Have you recently (within the last {X} days or weeks) used any arts and crafts products such as adhesive, glaze, glue, primer, varnish, etc?

Yes

No

If so, list the commercial or brand name of those.



Drinking Water

Have you had your drinking water tested?

Yes

No

DK

If so, what did the results show?



On average, for the past month, how many days did you use lead solder to solder pipes, do electric repairs?


    • Never

    • 1-3 days per month

    • 1-2 days per week

    • 3-6 days per week

    • Daily

    • Don’t know


Lifestyle Questions


Script: Sometimes our lifestyle can contribute to an increase or decrease in the chemical levels found our body. Answer the following questions about lifestyle.


Have you had a meal high in fat (fried fish, hamburgers, etc) in the X days?

Yes

No

Medicine Questions


Script: Some medicines may contain small amounts of chemicals and can affect your test results. Please answer the following questions about medicines you are taking.


Please list the prescription medications you now take.









Please list any over the counter medications such as vitamins, supplements (herbal and nutritional), acetaminophen (Tylenol) taken on a daily basis.






For medicines you do not take frequently (in the past few days), when was the last time you took that medicine?


Frequency of Contact Questions

Script: Script - You may have had contact with chemicals from more than one place. Please answer these questions on where you believe you had the most contact with chemicals. "Contact" means breathing, touching, swallowing/eating/ingesting. "Chemicals" means (dust, paints, glues, cleaning fluids, pesticides, weed killer, etc.)

Answer the following questions on a scale of 1 to 4, 1 meaning "less" and 4 meaning "more." Where do you believe you have more frequent contact with chemicals?

Work

Less

1

2

3

4

More

Hobbies


1

2

3

4


Home


1

2

3

4


Lifestyle


1

2

3

4


Foods


1

2

3

4



Answer the following questions on a scale of 1 to 4, 1 meaning "less" and 4 meaning "more." Where do you believe you have the most amount of contact with chemicals?

Work

Less

1

2

3

4

More

Hobbies


1

2

3

4


Home


1

2

3

4


Lifestyle


1

2

3

4


Foods


1

2

3

4




Confounders/Other Possible Sources of Exposure Questions

Chemical-Specific Set

Food, Drink, Medicines

Script: Sometimes chemicals are naturally found, can accumulate in, or are added to foods. Answer the following questions about food, drinks, or medicines you have had recently.

Arsenic

Have you eaten seafood (finfish, shellfish like oysters, crabs. mussels, lobster, or other like octopus, squid, etc) in the past 3-4 days?

Yes

No

Have you used any herbal supplements or remedies imported from India (containing avurvedic medicine) or imported from South Asia in the {past X} days?


(Note: Asian herbal remedy Kushtay may contain Ar)

Yes

If yes, please list them:

No

Have you eaten [INSERT FOOD] in the past [INSERT TIMEFRAME]?

Yes

If yes, please list them:

No

Mercury

When was the last time you ate fish?

Days

Weeks

Months

Have you used any herbal supplements or remedies imported from India (containing avurvedic medicine) or imported from South Asia in the {past X} days?

Yes

If yes, please list them:

No

Do you or your family members use mercury for medicinal or ceremonial purposes?

Yes

No

PCBs

When was the last time you ate seafood (finfish, shellfish like oysters, crabs. mussels, lobster, or other like octopus, squid, etc)?

Days

Weeks

Months

Years

PAHs

In the last month, have you eaten any food that was grilled, blackened, charred, smoked or roasted through cooking?

Yes

No

How many servings?

1-2

3-5

6-10

11-19

20+

In the last [INSERT TIMEFRAME], have you had any drinks that were roasted through cooking? (e.g., roasted coffee)?

Yes

No

If so, how many servings?

1 to 2

3 to 5

6 to 10

11 to 19

More than 20

Naphthalene

{Do you/Does she/Does he} use toilet bowl deodorizers inside {your/her/his} home?


[Some toilet bowl deodorizers clip onto the toilet rim, others, such as deodorant blocks and gels, are placed inside the tank or hang inside the wall of the tank. Brand names include Bully, 2000 Flushes, Vanish, X-14, Ty-D-Bol, Toilet Duck, Clorox, Lime-A-Way, and Sno Bol.]


[NOTE: Naphthalene is also used for in fungicides, lubricants, explosives, and wood preservatives. There are questions for those under Confounders/Other Possible Sources of Exposure Questions.]

Yes

No

{Do you/Does she/Does he} use moth balls or crystals inside {your/her/his} home?

Yes

No

Fluoride, other Chemicals?

Do you or your family members drink tea?

Yes

No

Lead

Have you eaten candies produced in Mexico in the past 2 months?

Yes

No

Have you used any herbal supplements or remedies imported from India (containing avurvedic medicine) or imported from South Asia in the {past X} days?


(Note: Bint al Thahab, some calcium supplements, Chinese herbal medicine, surma)

Yes

If yes, please list them:

No

Lifestyle Questions


Script: Sometimes our lifestyle can contribute to an increase or decrease in the chemical levels found in our body. Answer the following questions about lifestyle.


Cadmium

Cadmium is a heavy metal that is found in cigarette smoke, semiconductor manufacturing, welding, battery manufacturing, and metal smelting operations.

Have you or could you have had contact with Cadmium at your job?

Yes

No

Do you smoke cigarettes now?

Yes

No

How often do you smoke cigarettes?

Daily

Weekly

Monthly

How many cigarettes do you smoke per day?

1-5 day

6-10 day

11-20 day

>20

Does anyone smoke cigarettes inside your home including household members and frequent guests?

Yes

No

How often do household members or guests smoke cigarettes in your home?

Daily

Weekly

Monthly

PAHs

Do you smoke cigarettes now?

Yes

No

How often do you smoke cigarettes?

Daily

Weekly

Monthly

How many cigarettes do you smoke per day?

1-5 day

6-10 day

11-20 day

>20

Does anyone smoke cigarettes inside your home including household members and frequent guests?

Yes

No

How often do household members or guests smoke cigarettes in your home?

Daily

Weekly

Monthly

Health Conditions


.may be used for lead, uranium, cadmium, benzene


Script: Sometimes a health condition can contribute to an increase or decrease in the chemical levels found in our body. Answer the following questions about your health conditions.

Do you or have you had any of the medical problems below?

Diabetes type I or II

Kidney disease

High Blood Pressure

Anemia, from low iron

Bone problems or disease (like osteoporosis or “brittle bones”)

Chronic Respiratory Illness such as Asthma and Chronic Obstructive Pulmonary Disease (COPD)

Sickle Cell Anemia or Trait

G-6-P-D deficiency


If yes, give details


Are there times when your condition gets worse? (e.g., night, day weekend, weekday)

Yes

When?

No

Are there any places when your conditions get worse? (e.g., home, work, school)

Yes

When?

No

Are there any seasons when your conditions get worse? (e.g., spring, summer, fall, winter)

Yes

When?

No



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