Fillable Printable VA Form 10-0445
Fillable Printable VA Form 10-0445
VA Form 10-0445
OCCUPATIONAL AND ENVIRONMENTAL
EXPOSURE HISTORY
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.
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.
SERVICE BRANCHRATING/SPECILTYTASKS 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.
INDUSTRYDESCRIPTIONYEARS 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.
Paints/Varnishes
SUBSTANCEHRS PER WEEKYEARSSUBSTANCEHRS PER WEEKYEARS
Glues or Adhesives
Organic solvents
Pesticides
Gasoline or Oil
Products
Grain dusts, hay, or
other
Vegetable matter
Metals and metal
grinding
Animal husbandry
PATIENT'S NAME:PATIENT'S SSN:
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Have you ever worked in a moldy or musty environment?
Do you, or have you ever kept birds as pets?
Occupational Exposure History
YES NO
Have you worked in a building (other than your home) with sustained water problems?YES NO
Have you ever worked in a building (other than your home) with moldy or musty
odors?
YES NO
Have you ever worked in a moldy or musty environment?YES NO
If you were exposed to mold explain how.
Have you ever worked with the materials listed below? Check those that apply, indicate if particles were visible and the and
indicate the average hours per week and number of years you worked with each substance.
Asbestos
SUBSTANCEHRS PER WEEKYEARSPARTICLES WERE VISIBLE
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
YESNO
NOYES
Wood dust
Coal dust
Sand/stone dust
Abrasive blasting
Beryllium
Non-skid coating
Other type of dust
Metals
Dusts/fumes
Metalworking fluids
If you were exposed to any of these materials explain how.
Hobbies and Pastimes
Do you regularly garden or work with compost?
YESNO
Do you use pesticides?
YESNO
Do you do wood-working projects?
YESNO
PATIENT'S SSN:PATIENT'S NAME:
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NOYES
Does your basement have water problem?
NOYES
NOYES
YESNO
NOYES
NOYES
YESNO
Has your basement ever flooded?
Is your kitchen stove exhausted to the outside from a range hood?
Is air from your bathroom exhausted to the outside?
Is there mold growth on your bathroom wall?
Is there mold growth on your shower curtain?
Home/housing - Have you lived in a house with the following problems since leaving military service
Does your basement have a musty or moldy odor?
Environmental Exposure History
If you have lived in a home with these problems describe the issue including dates and duration of stay.
PATIENT'S SSN:
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PATIENT'S NAME:
