Environmental History and Lifestyle Health Questionnaire Form
Please complete this questionnaire to provide information on your environmental exposures and lifestyle habits relevant to your general health.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Residential Environment
*
Urban
Suburban
Rural
Other
Occupational Exposure to Environmental Hazards
None
Dust
Chemicals
Fumes
Noise
Other
Tobacco Use
*
Never
Former
Current
Alcohol Consumption
*
Never
Occasionally
Regularly
Physical Activity Frequency
*
Rarely
1-2 times per week
3-5 times per week
Daily
Dietary Pattern
Omnivore
Vegetarian
Vegan
Other
Exposure to Secondhand Smoke
Never
Occasionally
Frequently
Additional Comments or Relevant Information
Submit
Should be Empty: