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*Please note, required fields are in red.

You May Print and Fax This Form to: 631-286-6046 or 631-867-3128

or You May Email This Form to: or
Are you completing this form for another individual?
If yes, please enter your contact information: Name, Phone, Email

PART I - Personal History of the Affected Individual

1a. Name:
1b. Phone:
1c. E-mail:
2. Sex:
3. Age Level:

4. Have you ever been diagnosed or treated for any respiratory or allergic condition?
If YES, Please Explain, If NO, Please Skip to Question 5
Does the condition still exist?
If YES, When do you usually suffer from it? If NO, Please Skip to Question 5
Are you taking prescription medicine for this condition?
If YES, Please list medications, If NO, Please Skip to Question 5
5. Do you wear contact lenses?
6. Do you smoke?
Are you regularly in contact with other smokers

PART II - Job Specifications

7a. In which building is the issue occurring?
7b. In which room # is the issue occurring?
7c. In what area of the room is the issue occurring?
8. What is your job title?
9. During the course of the day are you in close proximity to computer terminals or photocopiers?
If YES, What is the frequency of this contact? If NO, Please Skip to Question 10
10. What other machinery or office equipment do you come in contact with? Please list equipment or enter "None" in the field provided.

PART III - Environmental Situations Occurring Within the Facility -Please check all situations below you have experienced& describe where appropriate

11. Unusual Odors?
If YES, please describe:
12. Uncomfortable Temperatures?
If YES, please describe:
13. Noticeable Dust in the Air?
14. Noises?
If YES, please Describe:
15. Mustiness or a Stuffy Feeling?
16. Excessive Humidity or Dryness?
17. Other. Please Explain:
18. Are there any specific time frames when the above situations occur?

PART IV - Symptoms or Health Reports

19. Please note below, in your own words, any symptoms or ailments that you have experienced on a recurring basis that you feel may be related to the building:
20. Do you notice any relation to the ailments you experience with the situations and time frames listed in section III? Please Explain Below or enter "No":
21. Which ailments or symptoms dissipate after leaving the facility? Please Explain Below or enter "None":
22. Which ailments or symptoms continue after leaving the facility and for how long? Please Explain Below or enter "None":
23. Are you aware or suspicious of anything that may be the cause of the environmental situations, symptoms or ailments described above? Please Specify What and Why Below or enter "No":

October 21, 2018