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Free Toxicity Survey
Section I: Symptoms
Rate each of the following based upon your health profile for the past 90 days:
Select the corresponding number:
0
 Rarely or never Experience the Symptom
1
 Occasionally Experience the Symptom, Effect is Not Severe
2
 Occasionally Experience the Symptom, Effect is Sever
3
 Frequently Experience the Symptom, Effect is Not Severe
4
 Frequently Experience the Symptom, Effect is Severe

1.
 DIGESTIVE
0
1
2
3
4
a.
 Nausea and/or vomiting
b.
 Diarrhea
c.
 Constipation
d.
 Bloated feeling
e.
 Belching and/or passing gas
f.
 Heartburn
2.
 EARS
0
1
2
3
4
a.
 Itchy ears
b.
 Earaches, ear infections
c.
 Drainage from ear
d.
 Ringing in ears, hearing loss
3.
 EMOTIONS
0
1
2
3
4
a.
 Mood swings
b.
 Anxiety, fear, nervousness
c.
 Anger, irritability
d.
 Depression
e.
 Sense of despair
f.
 Apathy/ lethargy
4.
 ENERGY/ ACTIVITY
0
1
2
3
4
a.
 Fatigue/ sluggishness
b.
 Hyperactivity
c.
 Restlessness
d.
 Insomnia
e.
 Startled awake at night
5.
EYES
0
1
2
3
4
a.
 Watery, itchy eyes
b.
 Swollen, reddened or sticky eyelids
c.
 Dark circles under eyes
d.
 Blurred/ tunnel vision
6.
 HEAD
0
1
2
3
4
a.
 Headaches
b.
 Faintness
c.
 Dizziness
d.
 Pressure
7.
 LUNGS
0
1
2
3
4
a.
 Chest congestion
b.
 Asthma, Bronchitis
c.
 Shortness of breath
d.
 Difficulty breathing
8.
 MIND
0
1
2
3
4
a.
 Poor memory
b.
 Confusion
c.
 Poor concentration
d.
 Poor coordination
e.
 Difficulty making decisions
f.
 Stuttering, stammering
g.
 Slurred speech
h.
 Learning disabilities
9.
 MOUTH/ THROAT
0
1
2
3
4
a.
 Chronic coughing
b.
 Gagging, frequent need to clear throat
c.
 Swollen or discolored tongue, gums, lips
d.
 Canker sores
10.
 NOSE
0
1
2
3
4
a.
 Stuffy Nose
b.
 Sinus problems
c.
 Hay fever
d.
 Sneezing attacks
e.
 Excessive mucous
11.
 SKIN
0
1
2
3
4
a.
 Acne
b.
 Hives, rashes, dry skin
c.
 Hair loss
d.
 Flushing
e.
 Excessive sweating
12.
 HEART
0
1
2
3
4
a.
 Skipped heartbeats
b.
 Rapid heartbeats
c.
 Chest pain
13.
 JOINTS/MUSCLES
0
1
2
3
4
a.
 Pain or atches in joints
b.
 Rheumatoid arthritis
c.
 Osteoarthritis
d.
 Stiffness, limited movement
e.
 Pain, aches in muscles
f.
 Recurrent back aches
g.
 Feeling of weakness or tiredness
14.
 WEIGHT
0
1
2
3
4
a.
 Binge eating/ drinking
b.
 Craving certain foods
c.
 Excessive weight
d.
 Compulsive eating
e.
 Water retention
f.
 Underweight
15.
 OTHER
0
1
2
3
4
a.
 Frequent illness
b.
 Frequent or urgent urination
c.
 Leaky bladder
d.
 Genital itch, discharge

Section II: Risk of Exposure
Rate each of the following based upon your health profile for the past 120 days:
Select the corresponding number for questions 16a-16f:
0
 Never
1
 Rarely
2
 Monthly
3
 Weekly
4
 Daily

16.
 RISK OF EXPOSURE
0
1
2
3
4
a.
 How often are strong chemicalsused in your home? (bleaches, furniture polish, floor wax, window cleaners, oven cleaners etc.)
b.
 How often are pesticides used in your home?
c.
 How often do you have your home treated for insects?
d.
 How often are you exposed to dust, tobacco smoke, mothballs, incense, or varnish in your home or office?
e.
 How often are you exposed to nail polish, perfume, hair spray, and other cosmetics?
f.
 How often are you exposed to diesel fumes, exhaust fumes, gasoline fumes?

Select the corresponding number for questions 17a-17b:
0
 No
1
 Mild Change
2
 Moderate Change
3
 Drastic Change

17.
HEALTH CHANGE
0
1
2
3
a.
 Have you noticed any negative change in your health since you moved into your home or apartment?
b.
 Have you noticed any negative change in your health since you started your job?

Answer Yes or No and select the corresponding number for questions 18a-18d below:

18.
 WATER & AIR QUALITY
NO
YES
a.
 Do you have a water purification system in your home?
b.
 Do you have any indoor pets?
c.
 Do you have an air purification system in your home?
d.
 Are you a dentist, painter, farm worker or construction worker?

 

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