PFAS Exposure Assessment Questionnaire Name(Required) Today's Date(Required) MM slash DD slash YYYY Age(Required)Please enter a number from 1 to 110.Zip Code(Required)How many glasses of tap water do you drink in a day?Please enter a number greater than or equal to 0.Do you cook with tap water? Yes No Do you drink from water fountains at your place of work or a school? Yes No Do you drink bottled water more than once a week? Yes No If yes, what brand of bottled water do you drink? Does your home have any water filters on the house, under the sink, or on the faucets? Yes No Do you use water pitchers that are filtered? Yes No If you regularly drink certain bottled drinks, alcohol, or juices, please list them here. Do you use non-stick cookware? Yes No How many eggs do you eat each week? Please enter a number greater than or equal to 0.How much fish do you eat in a week?Please enter a number greater than or equal to 0.List the types of fish you eat. I.e. Salmon, grouper, shark, etc. How much shellfish do you eat in a week?Please enter a number greater than or equal to 0.How many clams do you eat in a month?Please enter a number greater than or equal to 0.Do you ever eat fish caught from a lake, stream, or river? Yes No How much milk, cheese, and yogurt do you eat each day? Please enter a number greater than or equal to 0.Do you ever eat wild game that someone hunted? Yes No Do you have a child under 2 years old? Yes No Are you currently breastfeeding? Yes No How many meals a week do you eat from Fast Food restaurants such as Chick-fil-a, Starbucks, MacDonalds, Wendy’s, Arby’s, Taco Bell, Burger King, and Sweetgreen?Please enter a number greater than or equal to 0.Do you eat microwave popcorn more than once a month? Yes No How many cups of coffee do you drink a week? Please enter a number greater than or equal to 0.Where do you work? What other places have you worked for longer than 6 months in the last 5 years? Have you ever worked in a fluorochemical manufacturing facility, or where PFAS-containing products are used, such as textile factories, carpet manufacturers, printing facilities, or food packaging manufacturing? Yes No Have you ever worked in electroplating, painting, textiles, or carpet installation or treatment? Yes No Have you, or do you treat your carpets, furniture, shoes, or clothing with water or stain resistant coatings? Yes No Have you ever been in the military, or lived near or on a military base? Yes No Have you ever been a firefighter or lived with a firefighter? Yes No Do you ever use soil amendments in your yard, potted plants, or garden? Yes No Do you wear outdoor rain gear regularly? Yes No Do you camp often? Yes No Do you wear wrinkle-free or no-iron clothing? Yes No Do you use wrinkle-free or no-iron sheets? Yes No Do you play the guitar regularly? Yes No Do you rock climb regularly? Yes No Do you play sports regularly on artificial turf? Yes No Do you surf or snow ski with waxed skis? Yes No Do you regularly work on cars or bicycles? Yes No What brand of dental floss do you use?
