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Toxicity Questionnaire



SECTION I - SYMPTOMS
1. Digestive 2. Ears 3. Emotions
0 1 2 3 4 Nausea and/or vomiting 0 1 2 3 4 Itchy ears 0 1 2 3 4 Mood Swings
0 1 2 3 4 Diarrhea 0 1 2 3 4 Earaches, ear infections 0 1 2 3 4 Anxiety, fear, nervousness
0 1 2 3 4 Constipation 0 1 2 3 4 Drainage from ears 0 1 2 3 4 Anger, irritability
0 1 2 3 4 Bloating 0 1 2 3 4 Ringing in ears, hearing loss 0 1 2 3 4 Depression
0 1 2 3 4 Belching, passing gas 0 1 2 3 4 Sense of despair
0 1 2 3 4 Heartburn 0 1 2 3 4 Apathy, lethargy
4. Energy/Activity 5. Eyes 6. Head
0 1 2 3 4 Fatigue, sluggishness 0 1 2 3 4 Watery, itchy eyes 0 1 2 3 4 Headaches
0 1 2 3 4 Hyperactivity 0 1 2 3 4 Swollen, red or sticky eyelids 0 1 2 3 4 Faint
0 1 2 3 4 Restlessness 0 1 2 3 4 Dark circles under eyes 0 1 2 3 4 Dizziness
0 1 2 3 4 Insomnia 0 1 2 3 4 Blurred, tunnel vision 0 1 2 3 4 Pressure
0 1 2 3 4 Startled awake at night
7. Lungs 8. Mind 9. Mouth/Throat
0 1 2 3 4 Chest congestion 0 1 2 3 4 Poor memory 0 1 2 3 4 Chronic coughing
0 1 2 3 4 Asthma, bronchitis 0 1 2 3 4 Confusion 0 1 2 3 4 Gagging, clear throat frequently
0 1 2 3 4 Shortness of breath 0 1 2 3 4 Poor concentration 0 1 2 3 4 Swollen/discolored tongue, gums, lips
0 1 2 3 4 Difficulty breathing 0 1 2 3 4 Poor coordination, clumsy 0 1 2 3 4 Canker sores
0 1 2 3 4 Difficulty making decisions
0 1 2 3 4 Stuttering, stammering
0 1 2 3 4 Slurred speech
0 1 2 3 4 Learning disabilities
10. Nose 11. Skin 12. Heart
0 1 2 3 4 Stuffy nose 0 1 2 3 4 Acne 0 1 2 3 4 Skipped heartbeats
0 1 2 3 4 Sinus problems 0 1 2 3 4 Hives, rashes, dry skin 0 1 2 3 4 Rapid heartbeats
0 1 2 3 4 Hay fever 0 1 2 3 4 Hair loss 0 1 2 3 4 Chest pain
0 1 2 3 4 Sneezing attacks 0 1 2 3 4 Flushing
0 1 2 3 4 Excessive mucus 0 1 2 3 4 Excessive sweating
13. Joints/Muscles 14. Weight 15. Other
0 1 2 3 4 Pain, aches in joints 0 1 2 3 4 Binge eating and/or drinking 0 1 2 3 4 Frequent illness
0 1 2 3 4 Rheumatoid arthritis 0 1 2 3 4 Crave certain foods 0 1 2 3 4 Frequent or urgent urination
0 1 2 3 4 Osteoarthritis 0 1 2 3 4 Excessive weight 0 1 2 3 4 Leaky bladder
0 1 2 3 4 Stiffness, limited movement 0 1 2 3 4 Compulsive eating 0 1 2 3 4 Genital itch, discharge
0 1 2 3 4 Pain, aches in muscles 0 1 2 3 4 Water retention
0 1 2 3 4 Recurrent back aches 0 1 2 3 4 Underweight
0 1 2 3 4 Feel weakness, tiredness
 
SECTION II - EXPOSURE
16. Environmental factors
Never Rarely Monthly Weekly Daily How often are strong chemicals used in your home? (disinfectants, bleaches, oven cleaner, drain cleaner, furniture polish, floor wax, window cleaners, etc)
Never Rarely Monthly Weekly Daily How often are pesticides used in your home?
Never Rarely Monthly Weekly Daily How often do you have your home treated for insects?
Never Rarely Monthly Weekly Daily How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs, incense or varnish in your home or office?
Never Rarely Monthly Weekly Daily How often are you exposed to nail polish, perfumes, hair spray or other cosmetics
Never Rarely Monthly Weekly Daily How often are you exposed to diesel fumes, exhaust fumes or gasoline fumes?
17. Recent Changes
No Mild Moderate Drastic Have you noticed any negative change in your health since you moved into your house/apartment?
No Mild Moderate Drastic Have you noticed any negative change in your health since you started your job?
18. Other factors
No Yes Do you have a water purification system in your home?
No Yes Do you have any indoor pets?
No Yes Do you have an air purification system in your home?
No Yes Are you a dentist, painter, farm worker or construction worker?