Parkinson’s Trichloroethylene Exposure Questionnaire - Environmental Health Research Group

First Name *

Last Name *

Street Address *

Street address which includes street number and street name. Example: 123 Main St

City *

State *

State (2-letter designation i.e. NY for New York)

E-mail *

Phone

Phone number (will not be shared or displayed)

Have you been diagnosed with Parkinson’s? *

Yes

If so, when and by whom?

Previous Places of Residence

Address and Dates at that address

Address and Dates at that address 2

Address and Dates at that address 3

Address and Dates at that address 4

Where were you born? *

When were you born? *

Address where you lived when you were born?

Any family members or neighbors diagnosed with Parkinson’s?

Special Concerns

Occupational History

Firm name, address, job description, period of occupation

Firm name, address, job description, period of occupation 2

Firm name, address, job description, period of occupation 3

Have you worked in a factory, commercial business, military facility or any occupational setting where you used, handled or were exposed to trichloroethylene, solvents or other toxic chemicals?

Yes

These could include manufacturing operations, dry cleaners, electronics production, metal fabrication, machine shops, auto repair businesses, printing operations, gas and electric utility systems, chemical production plants, electroplating businesses and these industrial classifications.

Have you ever lived in the immediate vicinity of any of the below-referenced government-documented sources of trichloroethylene? *

Yes

See: Selected Trichloroethylene (TCE) Public Health and Environmental Threats That Reportedly Do Not Meet Cleanup Requirements

Explain

Have you ever lived in a home/apartment or worked in a building with a sub-slab depressurization system that might have been installed to mitigate soil gas vapor intrusion of trichloroethylene or other volatile chemical solvents? *

Yes

See: Examples of Sub-Slab Depressurization Systems

Explain

Has your drinking water ever been contaminated with trichloroethylene or other volatile chemical solvents? *

Yes

Explain

Were you ever were exposed to environmental contamination associated with trichloroethylene or other volatile chemical solvents? *

Yes

Explain

Have you been getting slower in your usual daily activities? *

Yes

Explain

Is your handwriting smaller? *

Yes

Explain

Is your speech slurred or softer? *

Yes

Explain

Do you have trouble rising from a chair? *

Yes

Explain

Do your lips, hands, arms and/or legs, etc. shake? *

Yes

Explain

Have you noticed more stiffness? *

Yes

Do you have trouble fastening buttons or dressing? *

Yes

Do you shuffle your feet and/or take smaller steps when you walk? *

Yes

Do your feet seem to get stuck to the floor when walking or turning? *

Yes

Have you or others noticed that you don’t swing one arm when walking? *

Yes

Do you have more trouble with your balance? *

Yes

Have you or others noticed that you stoop or have abnormal posture? *

Yes