Environmental Influences Questionnaire

Name
First Last
There are over 70,000 chemicals commercially produced in the United States. The long-term effects of many of these chemicals have never been investigated. But many chemicals are harmful in very low doses. Unless generated by the body (formaldehyde, pentane), the body’s level for chemicals should be non-detectable, and not “low level”. Chemicals are widespread in our environment, and constant exposure to low levels can cause dysfunction in many systems of the body. The purpose of the following questions is to determine if any of your health problems can be a result of chemical toxicity and to measure your TOTAL TOXIN LOAD.
Date
MM slash DD slash YYYY
Email
What is your occupation?*
Electromagnetic Factors*
- Live or have you lived within 200 yards from high-voltage wires or transformers?
- Lived or have lived near an electric distribution substation?
- Have a fan directly over your bed?
- Bed is close to the main electrical current.
- Have an alarm clock or radio close to your bed (plugged in)
- Live or have your lived near a television transmitter
- Sleep with an electric blanket, heating pad
- Sleep on a waterbed
- Work on a computer for longer than six hours a day
- Live or have you lived near a power generating station
- Live near a radio tower
- You use a cellular phone more than 2 hours a day
- Use microwave ovens
- Bed has a wooden backboard
- Have fluorescent light fixtures
- None of the above
Position of your head of your bed is facing:*
Trichloroethylene/TCE Exposure*
- Work close to a copy machine
- Worked in a printing shop
- Drink decaffeinated coffee
- Use rug cleaners
- Use disinfectants
- Use carbonless paper
- Use spot removers
- Use cleaning supplies
- Use metal degreasers
- Do recreational painting
- None of the above
Formaldehyde exposure*
- Wear many dry-cleaned clothers
- Noticed changes of your health since you moved into your home
- Wear many polyester clothes and permanent press
- You use Spray Starch
- Have foam wall insulation
- Have particleboard, chip board or interior plywood
- Put up wallpaper in the last 2 years
- Have a foam cushions or foam mattresses
- Live or lived in a trailer
- Worked in a laboratory
- Your home been insulated since your illness
- Recently had new carpets
- Use waxes and polishes on your floor
- Been around resin glues and plastics
- Have exterior grade plywood on your home
- Home made of stucco, plaster or concrete
- Have a wood-burning stove
- Have draperies
- Have used acid-cured resin floor finishes
- Have fire-proof material in your home
- Smoke in your home
- Have a photography darkroom
- Use nail polish remover
- Use fingernail hardeners
- None of the above
Pesticides & Herbicides (Organochlorines, Organophosphate, Carbamate, Chlorinate Cyclodiene, Botanical & Microbial)*
- Use pesticides
- Use weed killer
- You use cleaning fluids, waxes
- Lived or worked at a dry cleaning plant
- Have been around wood preservatives
- Drink tap water
- Work with electrical equipment
- Have mothballs in your closets
- Gasoline fumes bother you
- Eat store bought meat
- Use insecticides
- Crop-surface sprays
- Aerosols
- Fumigants
- None of the above
Volatile Organic Compounds (Paradichlorobenzenes, toluene, ethers, ketones, propane,, polymers, tetrachloroethylene)*
- Had home painted in the last 2 years
- Used cleaning solvents
- Have soft vinyl floors
- Handle propane and butane
- Get your clothes dry-cleaned
- Store dry-cleaned clothes in closets
- Barbecue more than 2 times per month
- Work in a “tightly sealed building”
- Work close to a laser printer
- Use moth balls
- Have nylon carpet
- Use air fresheners
- Have a workshop in the home
- None of the above
Phenols*
- Household cleaners
- Nasal Sprays
- Styrofoam cups
- Cough Syrup
- Decongestants
- Hair Sprays
- Scented deodorants
- Scotch tape
- Newsprint
- Lysol
- Epoxy
- Listerine
- Chloraseptic throat sprays
- Noxema
- Mildew cleaners
- Perfumes
- Air Fresheners
- Disinfectants
- Polishes
- Glues
- Waxes
- Mouthwash
- Hard saucepan handles
- Smoke in the house
- Have been exposed to chemicals
- Home treated for termites
- None of the above
Carbon Monoxide/Nitrogen Oxide/Sulfur Dioxide*
- Have oil or gas stove
- Chimney is damaged
- Live near a busy street
- Garage attached to your home
- Smoke at home
- Have an open fireplace
- Burn candles
- None of the above
Ozone*
- Use an electrical sewing machine
- Use power tools
- Use ion generators
- Work close to a photocopier
- None of the above
Carbon Dioxide*
- Work in a crowded work place
- Have poor ventilation at work
- None of the above
Asbestos*
- Live in an old home
- Have old ceiling tiles, plaster, insulation board and heating duct tape
- Lived in a large city with many trucks, buses, etc.
- Mother exposed to any unusual chemicals or drugs during pregnancy (DES)
- Do you have your nails treated? Acrylic Adhesives
- None of the above
Do you use Latex products?*
- Baby bottle nipples
- Balloons
- Bandages
- Diaphragms
- Hot water bottles
- Latex gloves
- Dishwashing gloves
- Rubber dams for dental work
- Tires
- Worked in a rubber industry
- None of the above
General Miscellaneous*
- Have basement Molds
- Home is damp
- Use a humidifier
- Use black hair dye (Nitrosamines)
- Worked in a beauty shop
- Take any illicit drugs as an adolescents/young adult?
- Open your windows at home
- Work in a machine shop
- Work in a garden
- Work or have you worked on a farm
- Have mercury fillings
- Had mercury fillings removed
- Been exposed to radiation
- Have a hot tub
- Use chlorine or bromine
- Have a well
- Work around PVC pipe (Vinyl chloride)
- Home well ventilated
- Moved to a new office in the last two years
- Live in an old apartment
- Eat at salad bars
- Eat raw fish (sushi)
- Buy food from street vendors
- Women: Saline breast implants
- Women: Silicone breast implants
- Any metal implants or joint replacements
- Notice more symptoms at work than at home or vice versa
- Symptoms get worse going into a mall
- Have you ever worked in a mall
- Have live plants in your home
- Have pets in your home
- Owned a new vehicle since your symptoms began
- Furniture been put in storage or possible fumigated
- Stained furniture in the last 2 years
- Have a tool shop in your garage
- Live on or near a golf course
- Live in or near an industrial area
- Lived or traveled outside of the US
- Bought new furniture
- Installed drop ceilings
- Painted indoors
- Sided your home
- Changed your heating system, stove, cloths dryer or water heater
- Lived in a brand new home
- Lived in a new office
- Noticed changes of your health since you moved into your home
- Have a water purification system
- Live near a landfill
- Have a water filter in your shower
- None of the above
Describe the contents of your bedroom*
- Have hardwood floors
- Have carpeting
- Have blinds
- Have draperies
- Use a foam pillow
- Use a feather pillow
- Use a Dacron pillow
- Use wool blanket
- Use cotton blankets
- Use quilts
- Use synthetic blankets
- Use an electric blanket
- Have a ceiling fan
- Have material under your bed
- Have real plants in your bedroom
- Have artificial plants in your bedroom
- Use aromatherapy in your bedroom
- Burn scented candles in your bedroom
- Have central heat
- Have a fireplace in your room
- Have an electric baseboard
- Use gas heat
- Use an air filter in your bedroom
- Have central air conditioning
- Sleep with your windows open
- Live close to a high traffic road
- Smoke in bed
- Allow any pet in your bed
- Have plugged in air fresheners
- None of the above
Art and Leisure Activities*
- Silk-screening
- Make stained glass
- Make potter & ceramic products
- Make jewelry
- Buy art and craft supplies
- Do quilting and weaving
- Gardening
- Make soapstone carvings
- Use acrylic paint
- None of the above
What hobbies do you have? Please list:*
Please indicate the occupation of your parents during your childhood.*
What brand of toothpaste paste do you use?*
What brand of Hair Conditioner do you use?*
What brand of Makeup do you use?
What brand of lipstick do you use?
What brand of Make-up Foundation do you use?
What brand of Deodorant do you use?*
What brand of Perfume do you use?
What brand of Hairspray do you use?
What brand of Shaving Cream do you use?
What brand of Cologne do you use?
What brand of Facial/Body Creams do you use?
Do you have hair permanents? Yes/No how If yes, how often?
Do you have hair colorings? Yes/No If yes, permanent or temporary?
Any other additional information we should know about? Any changes that might have occurred around the time you started getting ill, etc.?
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