example@example.com

Please enter a valid phone number.Format: (000) 000-0000.

Rows	0 = Rarely/Never	1 = Occasionally/Not Severe	2 = Occasionally/Severe	3 = Frequently/Not Severe	4 = Frequently/Severe
Nausea and/or vomiting
Diarrhea
Constipation
Bloated feeling
Belching and/or passing gas
Heartburn

Rows	0 = Rarely/Never	1 = Occasionally/Not Severe	2 = Occasionally/Severe	3 = Frequently/Not Severe	4 = Frequently/Severe
Itchy ears
Earaches or ear infections
Drainage from ear
Ringing in ears or hearing loss

Rows	0 = Rarely/Never	1 = Occasionally/Not Severe	2 = Occasionally/Severe	3 = Frequently/Not Severe	4 = Frequently/Severe
Mood swings
Anxiety, fear, or nervousness
Anger, irritability
Depression
Sense of despair
Uncaring or disinterested

Rows	0 = Rarely/Never	1 = Occasionally/Not Severe	2 = Occasionally/Severe	3 = Frequently/Not Severe	4 = Frequently/Severe
Fatigue or sluggishness
Hyperactivity
Restlessness
Insomnia
Startled awake at night

Rows	0 = Rarely/Never	1 = Occasionally/Not Severe	2 = Occasionally/Severe	3 = Frequently/Not Severe	4 = Frequently/Severe
Watery or itchy eyes
Swollen, reddened, or sticky eyelids
Dark circles under eyes
Blurred or tunnel vision

Rows	0 = Rarely/Never	1 = Occasionally/Not Severe	2 = Occasionally/Severe	3 = Frequently/Not Severe	4 = Frequently/Severe
Headaches
Faintness
Dizziness
d Pressure

Rows	0 = Rarely/Never	1 = Occasionally/Not Severe	2 = Occasionally/Severe	3 = Frequently/Not Severe	4 = Frequently/Severe
Chest congestion
Asthma or bronchitis
Shortness of breath
Difficulty breathing

Rows	0 = Rarely/Never	1 = Occasionally/Not Severe	2 = Occasionally/Severe	3 = Frequently/Not Severe	4 = Frequently/Severe
Poor memory
Confusion
Poor concentration
Poor coordination
Difficulty making decisions
Stuttering, stammering
Slurred speech
Learning disabilities

Rows	0 = Rarely/Never	1 = Occasionally/Not Severe	2 = Occasionally/Severe	3 = Frequently/Not Severe	4 = Frequently/Severe
Chronic coughing
Gagging or frequent need to clear throat
Swollen or discolored tongue, gums, lips
Canker sores

Rows	0 = Rarely/Never	1 = Occasionally/Not Severe	2 = Occasionally/Severe	3 = Frequently/Not Severe	4 = Frequently/Severe
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucous

Rows	0 = Rarely/Never	1 = Occasionally/Not Severe	2 = Occasionally/Severe	3 = Frequently/Not Severe	4 = Frequently/Severe
Acne
Hives, rashes, or dry skin
Hair loss
Flushing
Excessive sweating

Rows	0 = Rarely/Never	1 = Occasionally/Not Severe	2 = Occasionally/Severe	3 = Frequently/Not Severe	4 = Frequently/Severe
Skipped heartbeats
Rapid heartbeats
Chest pain

Rows	0 = Rarely/Never	1 = Occasionally/Not Severe	2 = Occasionally/Severe	3 = Frequently/Not Severe	4 = Frequently/Severe
Pain or aches in joints
Rheumatoid arthritis
Osteoarthritis
Stiffness or limited movement
Pain or aches in muscles
Recurrent back aches
Feeling of weakness or tiredness

Rows	0 = Rarely/Never	1 = Occasionally/Not Severe	2 = Occasionally/Severe	3 = Frequently/Not Severe	4 = Frequently/Severe
Binge eating or drinking
Craving certain foods
Excessive weight
Compulsive eating
Water retention
Underweight

Rows	0 = Rarely/Never	1 = Occasionally/Not Severe	2 = Occasionally/Severe	3 = Frequently/Not Severe	4 = Frequently/Severe
Frequent illness
Frequent or urgent urination
Leaky bladder
Genital itch, discharge

Rows	0 = Never	1 = Rarely	2 = Occasionally	3 = Frequently	4 = Daily
How often are strong chemicals used in your home? (disinfectants, bleaches, oven and drain cleaners, furniture polish, floor wax, window cleaners, etc.)
How often are pesticides used in your home?
How often do you have your home treated for insects?
How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs, incense, or varnish in your home or office?
How often are you exposed to nail polish, perfume, hairspray, or other cosmetics?
How often are you exposed to diesel fumes, exhaust fumes, or gasoline fumes?

Rows	0 = No change	1 = Mild	2 = Moderate	3 = Severe
Have you noticed any negative change in your health since you moved into your home or apartment?
Have you noticed any change in your health since you started your new job?