Toxin Exposure Questionnaire - Child

Table of contents:

If you have been exposed to any of these in the LAST 12 MONTHS please check:
? (Y) Yes
? (N) No
? (?) Unknown
? (P) for exposure before 12 months ago

Home and/or Work Environment

Do you have regular exposure to: Y N ? P Notes
Automobile exhaust
Farm/Industrial/Power plant or lines
Radio tower
Hydro tower
Do you live in a: (Circle one)
Apartment Building
Mobile Home
Do you work in a: (Circle one)
Office Building
Bathing/Showering water source: (Circle one)
Public Works
Do you have regular exposure at home or work to:
Forced air heat
Renovations (new carpets; add ons; etc…)
Basement cracks or dirt floor
Damp basement or crawl space
Wet windows or outside closet walls
Water leaks (ceilings, walls, floors)
Visible mold
Old or cracking ceiling tiles
Old or cracking vinyl linoleum flooring
Crumbling pipe insulation
Crumbling wall or ceiling insulation
Old or cracking paint
Carpets or rugs
Stagnant or stuffy air
Gas or propane stove
Coal or wood stove
Other gas appliance (water heater, furnace)
Regular contact with smokers

Hobby and Work Activities
Do you have regular exposure to: Y N ? P Notes
Pesticides or herbicides
Harsh chemicals (varnish, glue, gas, acid…)
Welding or soldering
Metals (Lead, Mercury, etc)
Photo developing / Dark room
Airplane travel
Cleaning chemicals

Food and drink:
Drinking/Cooking water source:
Public Works
Caffeine? What kind:
How Much:
Do you regularly eat: Y N ? P Notes
Fish (fresh, frozen, canned, etc.)
Artificial sweeteners (Circle one): NutraSweet, Equal, Aspartame, Splenda
Animal products
? How often?
? What percentage of your animal product is organic?
Do you wash your produce
? What percentage of your produce is organic?
Deep fat fried foods
Sodas, juices, drinks containing High Fructose Corn Syrup – how many per day?

Sensitivity to smells (gas, perfume, paint, etc…)
Artificial materials in the body (implants, pins, joints, etc…)

Have you ever: Y N ?
Used tobacco
Experimented with recreational drugs
Led a high stress lifestyle
Experienced a stressful or traumatic event
Been under anesthesia
Had an illness during foreign travel
Had an illness while camping or hiking
Had food poisoning


Do you currently have amalgam fillings or caps?
? How many amalgam fillings do you have now?
Have you removed or lost dental fillings or caps?
Did you have fillings as a child?
? How many fillings did you have?
Did you have your Wisdom teeth removed?
? At what age?
? Any complications such as dry socket or abscesses?
Do you have any root canal treated teeth?
? How many and when were they placed?
Did your mother have dental fillings prior to giving birth to you?
? During her pregnancy with you?

Age of school building:
Location of school building: Rural City Suburban
Do you have regular exposure at school to: Y N ? P Notes
Automobile exhaust
Farm/Industrial/Power plant or lines
Radio tower
Water tower
Renovations (carpeting, ceiling tiles, rooms)
Outdoor activities (recess, sports, etc.)

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