1. Have you ever been exposed to (possibly inhaled) asbestos fibers in the workplace?
   Yes    No
2. Have you been exposed to (possibly inhaled) asbestos fibers at home or in another non - work environment?
   Yes    No
3. If you were exposed in the past, what is the approximate total time of your exposure?
   Less than 1 year    2 to 5 years    6 to 10 years    More than 10 years
4. If you were exposed to asbestos in the past, how long a period of time has passed since your exposure?
   Less than 20 years    21 to 30 years    More than 30 years
5. Did you (do you) always wear a respirator or mask when you were (are) exposed to asbestos fibers?
   Yes    No
6. Do you smoke?
   Yes    No
7. Do you have any of the following symptoms?
   Shortness of breath    Chest pain    Abdominal pain or swelling

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