The forms below help EHP’s medical staff understand your environmental conditions and health concerns. To expedite your office visit, EHP encourages clients to print and complete forms at home and bring them to your appointment (along with any medical records or other available documentation).
EHP’s Public Health Nurse can provide you with additional information about which forms are needed for your particular situation.
- Survey for Patients’ Potential Exposure
- Individual Health Exposure Assessment
- Home Exposure Assessment
Our forms are also available in Spanish:
- Evaluación de Exposición de Salud del Individuo
- Evaluación de Exposición del Hogar Relacionada con las Actividades de Perforación Petrolera y de Gas
Please direct any questions to Jessa Chabeau, Case Manager jchabeau [at] environmentalhealthproject.org or 724-260-5504.