Toxin Exposure Questionnaire

Please mark your response for each of the following questions. Your provider will discuss your answers with you.

Do you eat conventionally-farmed (non-organic) or genetically-modified fruits and vegetables?

Yes

Sometimes

In the Past

Do you eat conventionally-raised (non-organic) animal products (e.g., meat, poultry, dairy, eggs)?

Yes

Sometimes

In the Past

Do you eat canned or farmed fish and seafood?

Yes

Sometimes

In the Past

Do you eat processed foods (e.g., foods with added artificial colors, flavors, preservatives), deep-fried foods, or fast foods?

Yes

Sometimes

In the Past

Do you drink water from a well, spring, or cistern, or from plumbing pipes or fixtures installed before 1986?

Yes

Sometimes

In the Past

Do you drink sodas, juices, or other beverages with natural or refined sweeteners (high-fructose corn syrup, cane sugar, agave nectar, stevia, undiluted fruit juice, etc.) or artificial sweeteners (i.e., Equal® or aspartame; Sweet’N Low®, Sugar Twin®, or saccharin; Splenda® or sucralose; Sunett®, Sweet One®, or acesulfame-K; and neotame)?

Yes

Sometimes

In the Past

Home and Work Environment

Do you live in an apartment or home built before 1978 or in a mobile home, boat, or recreational vehicle (RV)?

Yes

Sometimes

In the Past

Does your home or workplace contain new furniture, bedding, or construction materials (paint, laminate flooring, etc.)?

Yes

Sometimes

In the Past

Does your home or workplace show signs of mold or water damage (e.g., cracking paint, ceiling leaks, decaying insulation or foam, visible mold, or damp areas in windows, crawlspaces, or the basement)?

Yes

Sometimes

In the Past

Are you exposed to toxic substances (e.g., treated lumber; lead paint, paint chips, or dust; broken mercury thermometers or fluorescent bulbs) at home or work?

Yes

Sometimes

In the Past

Are you exposed to conventional cleaning chemicals, disinfectants, hand sanitizers, air fresheners, scented candles, or other scented products at home or work?

Yes

Sometimes

In the Past

Do you live or work near an industrial pollution source (e.g., highway, factory, incinerator, gas station, power plant)?

Yes

Sometimes

In the Past

Do you live or work near a source of electromagnetic radiation (cell phone tower, high-voltage power lines, etc.)?

Yes

Sometimes

In the Past

Do you live or work in an agricultural area or other area where you are exposed to herbicides, pesticides, or fungicides?

Yes

Sometimes

In the Past

Do you have woodburning, propane, or gas stoves or appliances at home or work?

Yes

Sometimes

In the Past

Do you live or work in a sealed building with recirculated air?

Yes

Sometimes

In the Past

Travel and Recreation

Do you go to parks, golf courses, or other outdoor or recreational areas treated with herbicides, pesticides, or fungicides?

Yes

Sometimes

In the Past

Do you travel by air?

Yes

Sometimes

In the Past

Do you run or bike to work along busy streets?

Yes

Sometimes

In the Past

Do you get sick while camping, hiking, or traveling (foreign or domestic)?

Yes

Sometimes

In the Past

Are you exposed to toxic chemicals as a result of a hobby (paints, photo-developing chemicals, epoxy adhesives, glues, varnishes, etc.)?

Yes

Sometimes

In the Past

Medical and Personal Care

Are you sensitive to personal care products like lotions, moisturizers, shampoos, conditioners, shaving creams, and soaps?

Yes

Sometimes

In the Past

Are you sensitive to smoke, perfumes, fragrances, cleaning products, gasoline, or other fumes?

Yes

Sometimes

In the Past

Do you smoke, or are you often exposed to secondhand smoke?

Yes

Sometimes

In the Past

Do you have a history of heavy use of alcohol or recreational or prescription drugs?

Yes

Sometimes

In the Past

Do you have any unusual reactions to anesthesia or to prescription or over-the-counter medications?

Yes

Sometimes

In the Past

Do you have root canals, extracted teeth, dental implants, “silver” fillings, crowns, dental sealants, dentures, retainers, aligning trays, braces, or mouth guards?

Yes

Sometimes

In the Past

Do you have food reactions, sensitivities, or intolerances?

Yes

Sometimes

In the Past

Do you have environmental allergies?

Yes

Sometimes

In the Past

Do you have any artificial materials in your body (implants, pins, joints, etc.)?

Yes

Sometimes

In the Past

Do you lead a high-stress lifestyle, or have you experienced a stressful or traumatic event?

Yes

Sometimes

In the Past