Toxicity Questionnaire

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Toxicity Questionairre

Stress Questionairre

Toxicity Questionnaire

First name

Last name

Phone

Section I: Symptoms

Digestive

a. Nausea and/or vomiting

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

b. Diarrhea

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

c. Constipation

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

d. Bloated feeling

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

e. Belching and/or passing gas

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

f. Heartburn

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

Ears

a. Itchy ears

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

b. Earaches or ear infections

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

c. Drainage from ear

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

d. Ringing in ears or hearing loss

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

Emotions

a. Mood swings

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

b. Anxiety, fear, or nervousness

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

ENERGY / ACTIVITY

a. Fatigue or sluggishness

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

b. Hyperactivity

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

c. Restlessness

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

d. Insomnia

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

e. Startled awake at night

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

Head

a. Headaches, Pressure

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

b. Faintness, Dizziness,

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

Lungs

a. Chest congestion, Asthma or bronchitis

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

b. Shortness of breath, Difficulty breathing

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

Eyes

a. Watery or itchy eyes

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

b. Swollen, reddened, or sticky eyelids

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

c. Dark circles under eyes

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

d. Blurred or tunnel vision

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

Mind

a. Poor memory

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

b. Confusion

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

c. Poor concentration

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

d. Poor coordination

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

e. Difficulty making decisions or Learning Disabilities

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

f. Stuttering, stammering

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

g. Slurred speech

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

Mouth / Throat

a. Chronic coughing

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

b. Gagging or frequent need to clear throat

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

c. Swollen or discolored tongue, gums, lips

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

d. Canker sores

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

a. Chronic coughing

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

Nose

a. Stuffy nose

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

b. Sinus problems

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

c. Hay fever

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

d. Sneezing attacks

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

e. Excessive mucous

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

Skin

a. Acne

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

b. Hives, rashes, or dry skin

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

c. Hair loss

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

d. Flushing

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

e. Excessive sweating

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

Heart

a. Skipped heartbeats

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

b. Rapid heartbeats

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

c. Chest pain

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

Joints / Muscles

a. Pain or aches in joints

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

b. Stiffness or limited movement

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

c. Pain or aches in muscles

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

d. Feeling of weakness or tiredness

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

Weight

a. Binge or Compulsive eating or drinking

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

b. Craving certain foods

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

c. Excessive weight

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

e. Water retention

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

f. Underweight

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

Other

a. Frequent illness

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

b. Frequent or urgent urination

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

c. Leaky bladder

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

d. Genital itch, discharge

0 - Rarely or Never Experience the Symptom

1 - Occasionally Experience the Symptom, Effect is Not Severe

2 - Occasionally Experience the Symptom, Effect is Severe

3 - Frequently Experience the Symptom, Effect is Not Severe

4 - Frequently Experience the Symptom, Effect is Severe

Section II: Risk of Exposure

a. How often are strong chemicals used in your home? (disinfectants, bleaches, oven and drain cleaners, furniture polish, floor wax, window cleaners, etc.)

c. Have you noticed any negative change in your health since you moved into your home or apartment?

0 - No

1 - Mild Change

2 - Moderate Change

3 - Drastic Change

d. Have you noticed any change in your health since you started your new job?

0 - No

1 - Mild Change

2 - Moderate Change

3 - Drastic Change

e. Do you have a water purification system in your home?

0 - No

2 - Yes

f. Do you have any indoor pets?

0 - No

2 - Yes

g. Do you have an air purification system in your home?

0 - No

2 - Yes

h. Are you a dentist, painter, farm worker, or construction worker?

0 - No

2 - Yes

Toxicity Questionnaire

Section I: Symptoms

Digestive

Ears

Emotions

ENERGY / ACTIVITY

Head

Lungs

Eyes

Mind

Mouth / Throat

Nose

Skin

Heart

Joints / Muscles

Weight

Other

Section II: Risk of Exposure

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