a

fl Other personal care products: I wears Makeup: I ehsh ] Mascara f] Face powder fl Eyelid powderfliner fl Foundation/base Remover I Concealer fl Lipsticlc/gloss/liner fl Moisturizer/cream I Toner/astringent I Masque f]cleanser flother: I Contact lenses: I Satine flLens cleaner(): I Jewelry: flWear daily f] Wear weekends fl Wear seldom ! Wear special occasions ' Type: ! Rings fl Watch flBracelet(s) Earrings ! Piercing(s) Necklace(s) Metals: ECota Isterling n Stainless steel flplatinum f]tti"tet plated D oth.r_ flTatoos: D New fl ou I Permanent I Temporary [ Henna-based f] Use Condoms/diaphragms: -JDaily l-JWeekly flMonthly I Occasionally Type:

Medical Devices:,1 [,-l tmptants flstents (including de,ntal) [l Braces E riningt fl Crowns/Bridges n othe.:

Employment,Eistory: Current errployer: Since (date):_ Since (date): Iob description: Same employer at onset of derrnatitis: n Yes fl No; employer at onset: Previous job description and duration: Regular contact: n Uetds n nust f]Fibers I Ruias f ] Vibration/col d/heat D Solvents I numes n Cnemicats D other: [] narety flnaity flWeekly flMonthly I ott": Describe work site:: I Factory n offi" flHospital flLaboratory flConstlction E Agrcuttre,' fl Indoors n outdoors n otlr"t WorkEquipment l-lGloves Boots I Face shield I Apron fl Maslc/respirator I Overalls I Badge flHeadcovering n Monito.s n *r"r Symptoms atworkq Since (date): Description of work when qrmptoms began: Materials associated with this work: [ freatrngnV I Docugrentation at place of employment: Effect of we-ekcnds/trolidays/vacations: I Improved n No change I worse Loss ofwork: E No I Yes, on dates: Otherworkers with same problem fl Uo I yes Previdus compensation claims: D No I Yes, for_ job: part-time Second f ,:] Futl time n f]"r, as:- Job descri

D-escribe work site: [.-l Fa"tory I offi"" n Hospital I Laboratory Constuction , I n Agncultue l_l Indoors L l Outdoors n oth"t Symptoms at'2nd job: n same fl different Since (date:

Notes: