• Format: (000) 000-0000.

  • Community Exposures

  • Automobile exhaust – regular exposure
  • Farm/Industrial/Power plant or lines – regular exposure
  • Radio tower – regular exposure
  • Landfill/Dump – regular exposure
  • Hydro tower – regular exposure

  • Home/Work Environment

  • Bathing/Showering water source*
  • Forced air heat – regular exposure
  • Renovations (new carpets, add ons, etc.) – regular exposure
  • Basement cracks or dirt floor – regular exposure
  • Damp basement or crawl space – regular exposure
  • Wet windows or outside closet walls – regular exposure
  • Water leaks (ceilings, walls, floors) – regular exposure
  • Visible mold – regular exposure
  • Old or cracking ceiling tiles – regular exposure
  • Old or cracking vinyl linoleum flooring – regular exposure
  • Crumbling pipe insulation – regular exposure
  • Crumbling wall or ceiling insulation – regular exposure
  • Old or cracking paint – regular exposure
  • Carpets or rugs – regular exposure
  • Stagnant or stuffy air – regular exposure
  • Gas or propane stove – regular exposure
  • Coal or wood stove – regular exposure
  • Other gas appliance (water heater, furnace) – regular exposure
  • Regular contact with smokers – regular exposure

  • Hobby/Work exposures

  • Pesticides or herbicides – regular exposure
  • Harsh chemicals (varnish, glue, gas, acid, etc.) – regular exposure
  • Welding or soldering – regular exposure
  • Metals (Lead, Mercury, etc.) – regular exposure
  • Paints – regular exposure
  • Photo developing / Dark room – regular exposure
  • Airplane travel – regular exposure
  • Cleaning chemicals – regular exposure

  • Personal / Diet

  • Drinking/Cooking water source
  • Caffeine use
  • Regularly eat fish
  • Regularly use artificial sweeteners
  • Regularly drink alcohol
  • Regularly eat animal products
  • Do you wash your produce?
  • Regularly eat deep fat fried foods

  • Personal

  • Do you have allergies*
  • Do you have sensitivity to smells*
  • Do you have artificial materials in the body*
  • Do you have immunizations*

  • History

  • Have you ever used tobacco?
  • Have you ever experimented with recreational drugs?
  • Have you ever led a high stress lifestyle?
  • Have you ever experienced a stressful or traumatic event?
  • Have you ever been under anesthesia?
  • Have you ever had an illness during foreign travel?
  • Have you ever had an illness while camping or hiking?
  • Have you ever had food poisoning?

  • Dental

  • Do you currently have amalgam fillings or caps?*
  • Have you removed or lost dental fillings or caps?
  • Did you have fillings as a child?
  • Did you have your wisdom teeth removed?
  • Do you have any root canal treated teeth?
  • Did your mother have dental fillings before giving birth to you?
  • Did your mother have dental fillings during her pregnancy with you?

  • Current prescription or over-the-counter medications

  • Vitamins/Minerals/Herbs/Other supplements

  • Drug adverse reactions

  • Should be Empty: