Occupational History

Occupational History
What type of work do you do? --> [textarea]
Have you had any of the following common exposures?
[checkbox name="Q1" value="acrylics|alcohols|chromium/chromates|cleansers|cobalt|cosmetics|cutting oils|degreasers|disinfectants|epoxy resins|nickel|petroleum|plants|preservatives|resins|solvents|wet work|other/not listed"][conditional field="Q1" condition="(Q1).is('other/not listed')"]
[textarea default="list or describe other exposures"][/conditional]
Are any of your coworkers experiencing similar symptoms? --> [select name="Q2" value="no|yes"][conditional field="Q2" condition="(Q1).is('yes')"]
[textarea default="describe"][/conditional]
Review of lifetime occupations and duties, including military history (Exposures may predate current occupation):
[textarea]
Assessment of hazard exposure (Route, duration, concentration of hazard)
[textarea]
Presence of controls
[checkbox name="Q3" value="Use of personal protective equipment|ventilation|diverting conveyors|enclosures|ergonomic workstations|devices to redistribute weight|other/not listed"][conditional field="Q3" condition="(Q3).is('other/not listed')"]
[textarea default="list or describe other controls"][/conditional]
Timing of symptoms in relation to work (Temporal relationship is crucial; however, many times, improvement away from work is not appreciated)
[textarea]
Exposure to nonoccupational hazards (Home environment, hobbies, recreational activities)
[textarea]

[checkbox memo="References (Hide/Show)" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).isNot('')"][link memo="Bepko J, Mansalis K. Common Occupational Disorders: Asthma, COPD, Dermatitis, and Musculoskeletal Disorders. Am Fam Physician. 2016 Jun 15;93(12):1000-6." url="https://www.ncbi.nlm.nih.gov/pubmed/27304769"][/conditional]