Va Form 10-0445 - Occupational And Environmental Exposure History Page 3
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3Environmental Exposure History
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?
YES
NO
Does your basement have water problem?
YES
NO
Has your basement ever flooded?
YES
NO
Is your kitchen stove exhausted to the outside from a range hood?
YES
NO
Is air from your bathroom exhausted to the outside?
YES
NO
Is there mold growth on your bathroom wall?
YES
NO
Is there mold growth on your shower curtain?
YES
NO
If you have lived in a home with these problems describe the issue including dates and duration of stay.
PATIENT'S NAME:
PATIENT'S SSN:
Page 3 of 3
10-0445
VA FORM
DEC 2006
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