Toxin Exposure Questionnaire

Date

Name

First NameMiddle NameLast Name

Date of Birth

Date

Email

example@example.com

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

Food and Water

	No	In the Past	Sometimes	Yes
1. Do you eat conventionally-farmed (non-organic) or genetically-modified fruits and vegetables?
2. Do you eat conventionally-raised (non-organic) animal products (e.g., meat, poultry, dairy, eggs)?
3. Do you eat canned or farmed fish and seafood?
4. Do you eat processed foods (e.g., foods with added artificial colors, flavors, preservatives), deep-fried foods, or fast foods?
5. Do you drink water from a well, spring, or cistern, or from plumbing pipes or fixtures installed before 1986?
6. 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)?

Home and Work Environment

	No	In the Past	Sometimes	Yes
1. Do you live in an apartment or home built before 1978 or in a mobile home, boat, or recreational vehicle (RV)?
2. Does your home or workplace contain new furniture, bedding, or construction materials (paint, laminate flooring, etc.)?
3. 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)?
4. 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?
5. Are you exposed to conventional cleaning chemicals, disinfectants, hand sanitizers, air fresheners, scented candles, or other scented products at home or work?
6. Do you live or work near an industrial pollution source (e.g., highway, factory, incinerator, gas station, power plant)?
7. Do you live or work near a source of electromagnetic radiation (cell phone tower, high-voltage power lines, etc.)?
8. Do you live or work in an agricultural area or other area where you are exposed to herbicides, pesticides, or fungicides?
9. Do you have woodburning, propane, or gas stoves or appliances at home or work?
10. Do you live or work in a sealed building with recirculated air?

Travel and Recreation

	No	In the Past	Sometimes	Yes
1. Do you go to parks, golf courses, or other outdoor or recreational areas treated with herbicides, pesticides, or fungicides?
2. Do you travel by air?
3. Do you run or bike to work along busy streets?
4. Do you get sick while camping, hiking, or traveling (foreign or domestic)?
5. Are you exposed to toxic chemicals as a result of a hobby (paints, photo-developing chemicals, epoxy adhesives, glues, varnishes, etc.)?

Medical and Personal Care

	No	In the Past	Sometimes	Yes
1. Do you go to parks, golf courses, or other outdoor or recreational areas treated with herbicides, pesticides, or fungicides?
1. Are you sensitive to personal care products like lotions, moisturizers, shampoos, conditioners, shaving creams, and soaps?
2. Are you sensitive to smoke, perfumes, fragrances, cleaning products, gasoline, or other fumes?
3. Do you smoke, or are you often exposed to secondhand smoke?
4. Do you have a history of heavy use of alcohol or recreational or prescription drugs?
5. Do you have any unusual reactions to anesthesia or to prescription or over-the-counter medications?
6. Do you have root canals, extracted teeth, dental implants, “silver” fillings, crowns, dental sealants, dentures, retainers, aligning trays, braces, or mouth guards?
7. Do you have food reactions, sensitivities, or intolerances?
8. Do you have environmental allergies?
9. Do you have any artificial materials in your body (implants, pins, joints, etc.)?
10. Do you lead a high-stress lifestyle, or have you experienced a stressful or traumatic event?

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