Toxin Exposure Questionnaire
Please check the best response for each of the following questions. Your provider will discuss your answers with you.
Name
First Name
Last Name
Email
example@example.com
Food and Water
Please check the best response for each of the following questions. Your provider will discuss your answers with you.
Do you consume conventionally-farmed (non-organic) or genetically-modified fruits and vegetables?
Yes
Sometimes
In the past
No
Do you consume conventionally-raised (non-organic) animal products (i.e., meat, poultry, dairy, eggs)
Yes
Sometimes
In the past
No
Do you consume canned or farmed fish and seafood?
Yes
Sometimes
In the past
No
Do you consume processed foods (i.e., foods with added artificial colors, flavors, preservatives, or sweeteners), deep-fried, or fast foods?
Yes
Sometimes
In the past
No
Do you drink water from a well, spring, or cistern, or from plumbing pipes or fixtures installed before 1986?
Yes
Sometimes
In the past
No
Do you drink sodas, juices, or other beverages with natural or refined sweeteners (i.e., high-fructose corn syrup, cane sugar, agave nectar, Stevia, undiluted fruit juice, etc.) or artificial sweeteners(i.e., NutraSweet/Equal/aspartame, Sweet’N Low/saccharine, Splenda/sucralose, Sunett/Sweet One/acesulfame K, neotame)?
Yes
Sometimes
In the past
No
Total Food and Water
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Next
Home and Work Environment
Please check the best response for each of the following questions. Your provider will discuss your answers with you.
Do you live in an apartment or home built before 1978, or in a mobile home, boat, or RV?
Yes
Sometimes
In the past
No
Does your home or workplace contain new construction materials or furniture (i.e., paint, laminate flooring, particle board, new carpeting, bedding, furniture, etc.)?
Yes
Sometimes
In the past
No
Does your home or workplace show signs of mold or waterdamage (i.e., cracking paint, ceiling leaks, decaying insulation or foam,visible mold, or damp windows, basement, or crawlspaces, etc.)?
Yes
Sometimes
In the past
No
Are you exposed to toxic substances (i.e., treated lumber, lead paint, paint chips or dust, broken mercury thermometers or fluorescent bulbs, etc.) at home or work?
Yes
Sometimes
In the past
No
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
No
Do you live or work near an industrial pollution source (i.e., highway, factory, incinerator, gas station, power plant, etc.)?
Yes
Sometimes
In the past
No
Do you live or work near a source of electromagnetic radiation (i.e., cell phone tower, high-voltage power lines, or other known source)?
Yes
Sometimes
In the past
No
Do you live or work in an agricultural area or another type of area where you are exposed to herbicides, pesticides, or fungicides?
Yes
Sometimes
In the past
No
Do you have wood-burning, propane, or gas stoves or appliances at home or work?
Yes
Sometimes
In the past
No
Do you live or work in a sealed building with recirculated air?
Yes
Sometimes
In the past
No
Total Home and Work Environment
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Travel and Recreation
Please check the best response for each of the following questions. Your provider will discuss your answers with you.
Do you frequent parks, golf courses, or other outdoor or recreational areas treated with herbicides, pesticides, or fungicides?
Yes
Sometimes
In the past
No
Do you travel by air?
Yes
Sometimes
In the past
No
Do you run or bike to work along busy streets?
Yes
Sometimes
In the past
No
Do you get sick while camping, hiking, or traveling (foreign or domestic)?
Yes
Sometimes
In the past
No
Are you exposed to toxic chemicals as a result of a hobby(i.e., paints, photo-developing chemicals, epoxy adhesives, glues, varnishes, etc.)?
Yes
Sometimes
In the past
No
Total Travel and Recreation
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Next
Medical and Personal Care
Please check the best response for each of the following questions. Your provider will discuss your answers with you.
Are you sensitive to personal care products like lotions, moisturizers, toners, shampoos, conditioners, shaving creams, and soaps?
Yes
Sometimes
In the past
No
Are you sensitive to smoke, perfumes, fragrances, cleaning products, gasoline, or other fumes?
Yes
Sometimes
In the past
No
Do you smoke, or are you often exposed to second-hand smoke?
Yes
Sometimes
In the past
No
Do you have a history of heavy use of alcohol, or recreational or prescription drugs?
Yes
Sometimes
In the past
No
Do you have any unusual reactions to anesthesia or to prescription or over-the-counter medications?
Yes
Sometimes
In the past
No
Do you have root canals, extracted teeth, “silver” fillings, crowns, dental sealants, dentures, retainers, aligning trays, braces, mouth guards, dental implants, etc.?
Yes
Sometimes
In the past
No
Do you have food reactions, sensitivities, or intolerances? Do you have environmental allergies?
Yes
Sometimes
In the past
No
Do you have any artificial materials in your body (implants, pins, joints, etc.)?
Yes
Sometimes
In the past
No
Do you lead a high-stress lifestyle, or have you experienced a stressful or traumatic event?
Yes
Sometimes
In the past
No
Total Medical and Personal Care
Total Toxic Exposure
Submit
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