Toxicity Questionnaire

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Section I: Symptoms
Rate each of the following based on your health profile for the past 90 days.
1. DIGESTIVE
a. Nausea and/or vomiting
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
b. Diarrhea
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
c. Constipation
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
d. Bloated feeling
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
e. Belching and/or passing gas
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
f. Heartburn
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
2. EARS
a. Itchy ears
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
b. Earaches or ear infections
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
c. Drainage from ear
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
d. Ringing in ears or hearing loss
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
3. EMOTIONS
a. Mood swings
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
b. Anxiety, fear or nervousness
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
c. Anger, irritability
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
d. Depresssion
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
e. Sense of despair
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
f. Uncaring or disinterested
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
4. ENERGY/ACTIVITY
a. Fatigue or sluggishness
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
b. Hyperactivity
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
c. Restlessness
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
d. Insomnia
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
e. Startled awake at night
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
5. EYES
a. Watery or itchy eyes
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
b. Swollen, reddened or sticky eyelids
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
c. Dark circles under eyes
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
d. Blurred or tunnel vision
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
6. HEAD
a. Headaches
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
b. Faintness
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
c. Dizziness
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
d. Pressure
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
7. LUNGS
a. Chest congestion
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
b. Asthma or bronchitis
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
c. Shortness of breath
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
d. Difficulty breathing
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
8. MIND
a. Poor memory
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
b. Confusion
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
c. Poor concentration
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
d. Poor coordination
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
e. Difficulty making decisions
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
f. Stuttering, stammering
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
g. Slurred speech
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
h. Learning disabilities
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
9. MOUTH/THROAT
a. Chronic coughing
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
b. Gagging or frequent need to clear throat
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
c. Swollen or discolored tongue, gums, lips
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
d. Canker sores
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
10. NOSE
a. Stuffy nose
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
b. Sinus problems
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
c. Hay fever
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
d. Sneezing attacks
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
e. Excessive mucous
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
11. SKIN
a. Acne
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
b. Hives, rashes or dry skin
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
c. Hair loss
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
d. Flushing
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
e. Excessive sweating
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
12. HEART
a. Skipped heartbeats
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
b. Rapid heartbeats
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
c. Chest pain
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
13. JOINTS/MUSCLES
a. Pain or aches in joints
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
b. Rheumatoid arthritis
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
c. Osteoarthritis
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
d. Stiffness or limited movement
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
e. Pain or aches in muscles
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
f. Recurrent back aches
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
g. Feeling of weakness or tiredness
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
14. WEIGHT
a. Binge eating or drinking
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
b. Craving certain foods
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
c. Excessive weight
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
d. Compulsive eating
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
e. Water retention
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
f. Underweight
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
15. OTHER
a. Frequent illness
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
b. Frequent or urgent urination
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
c. Leaky bladder
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
d. Genital itch, discharge
0- Rarely or Never
1- Occasionally, Effect is Not Severe
2- Occasionally, Effect is Severe
3- Frequently, Effect is Not Severe
4- Frequently, Effect is Severe
Section II: Risk of Exposure
Rate each of the following situations based on your environmental profile for the past 120 days.
16a. How often are strong chemicals used in your home?
(disinfectants, bleaches, oven and drain cleaners, furniture polish, floor wax, window cleaners,
etc.)
0- Never
1- Rarely
2- Monthly
3- Weekly
4- Daily
16b. How often are pesticides used in your home?
0- Never
1- Rarely
2- Monthly
3- Weekly
4- Daily
16c. How often do you have your home treated for insects?
0- Never
1- Rarely
2- Monthly
3- Weekly
4- Daily
16d. How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs, incense,
or varnish in your home or office?
0- Never
1- Rarely
2- Monthly
3- Weekly
4- Daily
16e. How often are you exposed to nail polish, perfume, hairspray or other cosmetics?
0- Never
1- Rarely
2- Monthly
3- Weekly
4- Daily
16f. How often are you exposed to diesel fumes, exhaust fumes or gasoline fumes?
0- Never
1- Rarely
2- Monthly
3- Weekly
4- Daily
17a. 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
17b. Have you noticed any changes in your health since you started your new job?
0- No
1- Mild Change
2- Moderate Change
3- Drastic Change