Va Form 10-0445 - Occupational And Environmental Exposure History
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3OCCUPATIONAL AND ENVIRONMENTAL
EXPOSURE HISTORY
Many chronic lung diseases can result from or be modified by a broad range of factors including genetics and family history;
personal habits such as smoking, diet, and exercise; random events such as infections; and exposures in the work place or the
home. Please complete the form and questions below to the best of your knowledge. The clinician examining you will review this
form and discuss possible factors that may be related to your disease.
List all jobs you held while in military service. List Navy Enlisted Code (NEC), Navy Officer Billet Codes (NOBC),
Military Occupational Specialties (MOS), or Air Force Specialty Codes (AFSC) if known. Provide a brief job description.
SERVICE BRANCH
RATING/SPECILTY
TASKS AND EXPOSURES
YEARS WORKED
List all jobs you have had held since completing high school. Include periods of unemployment greater than one year.
Provide a brief job description.Begin with your most recent job and work backwards.
INDUSTRY
DESCRIPTION
YEARS WORKED
While working at any of your past or present jobs, have you worked with any of the substances listed below? Check those
that apply and indicate the average hours per week and nuuber of years you worked with each substance.
SUBSTANCE
HRS PER WEEK
YEARS
SUBSTANCE
HRS PER WEEK
YEARS
Grain dusts, hay, or
Paints/Varnishes
other
Glues or Adhesives
Vegetable matter
Organic solvents
Metals and metal
Pesticides
grinding
Gasoline or Oil
Animal husbandry
Products
PATIENT'S NAME:
PATIENT'S SSN:
Page 1 of 3
10-0445
VA FORM
DEC 2006
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