Occupational and Environmental Health History Form (continued) Work History 1. List your current and past longest-held jobs, including the military. Company Dates employed Job title Known exposures _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ 2. Do you work full-time? No Yes How many hours per week? 3. Do you work part-time? No Yes How many hours per week? 4. Please describe any health problems or injuries that you have experienced in connection with your present or past jobs: 5. Have you ever had to change jobs due to health problems or injuries? If so, have any of your co-workers experienced similar problems? 6. In what type of business do you work currently? 7. Describe your work: 318 Source: Reprinted with permission from Nursing, Health, and the Environment. Copyright 1995 by the National Academy of Sciences. Courtesy of the National Academy Press, Washington, D.C. Rogers, B. Occupational and Environmental Health Nursing: Concepts and Practices, 3rd ed. Philadelphia: Saunders/Elsevier Science, in press.
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