Toxin Exposure Questionnaire

Photo by Amy (lydocia) on Unsplash

taken from the Institute for Functional Medicine

Food and Water

1.     Do you eat conventionally-farmed (non-organic) or genetically-modified fruits and vegetables?

Yes                 Sometimes                  In the Past                  No

2.     Do you eat conventionally-raised (non-organic) animal products (e.g., meat, poultry, dairy, eggs)?

Yes                 Sometimes                  In the Past                  No

3.     Do you eat canned or farmed fish and seafood?

Yes                 Sometimes                  In the Past                  No

4.     Do you eat processed foods (e.g., foods with added artificial colors, flavors, preservatives), deep-fried foods, or fast foods?

Yes                 Sometimes                  In the Past                  No

5.     Do you drink water from a well, spring, or cistern, or from plumbing pipes or fixtures installed before 1986?

Yes                 Sometimes                  In the Past                  No

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)?

Yes                 Sometimes                  In the Past                  No

Home and Work Environment

1.     Do you live in an apartment or home built before 1978 or in a mobile home, boat, or recreational vehicle (RV)?

Yes                 Sometimes                  In the Past                  No

2.     Does your home or workplace contain new furniture, bedding, or construction materials (paint, laminate flooring, etc.)?

Yes                 Sometimes                  In the Past                  No

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)?

Yes                 Sometimes                  In the Past                  No

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?

Yes                 Sometimes                  In the Past                  No

5.     Are you exposed to conventional cleaning chemicals, disinfectants, hand sanitizers, air fresheners, scented candles, or other scented products at home or work?

Yes                 Sometimes                  In the Past                  No

6.     Do you live or work near an industrial pollution source (e.g., highway, factory, incinerator, gas station, power plant)?

Yes                 Sometimes                  In the Past                  No

Home and Work Environment (continued)

7.     Do you live or work near a source of electromagnetic radiation (cell phone tower, high-voltage power lines, etc.)?

Yes                 Sometimes                  In the Past                  No

8.     Do you live or work in an agricultural area or other area where you are exposed to herbicides, pesticides, or fungicides?

Yes                 Sometimes                  In the Past                  No

9.     Do you have woodburning, propane, or gas stoves or appliances at home or work?

Yes                 Sometimes                  In the Past                  No

10. Do you live or work in a sealed building with recirculated air?

Yes                 Sometimes                  In the Past                  No

Travel and Recreation

1.     Do you go to parks, golf courses, or other outdoor or recreational areas treated with herbicides, pesticides, or fungicides?

Yes                 Sometimes                  In the Past                  No

2.     Do you travel by air?

Yes                 Sometimes                  In the Past                  No

3.     Do you run or bike to work along busy streets?

Yes                 Sometimes                  In the Past                  No

4.     Do you get sick while camping, hiking, or traveling (foreign or domestic)?

Yes                 Sometimes                  In the Past                  No

5.     Are you exposed to toxic chemicals as a result of a hobby (paints, photo-developing chemicals, epoxy adhesives, glues, varnishes, etc.)?

Yes                 Sometimes                  In the Past                  No

Medical and Personal Care

1.     Are you sensitive to personal care products like lotions, moisturizers, shampoos, conditioners, shaving creams, and soaps?

Yes                 Sometimes                  In the Past                  No

2.     Are you sensitive to smoke, perfumes, fragrances, cleaning products, gasoline, or other fumes?

Yes                 Sometimes                  In the Past                  No

3.     Do you smoke, or are you often exposed to secondhand smoke?

Yes                 Sometimes                  In the Past                  No

4.     Do you have a history of heavy use of alcohol or recreational or prescription drugs?

Yes                 Sometimes                  In the Past                  No

5.     Do you have any unusual reactions to anesthesia or to prescription or over-the-counter medications?

Yes                 Sometimes                  In the Past                  No

6.     Do you have root canals, extracted teeth, dental implants, “silver” fillings, crowns, dental sealants, dentures, retainers, aligning trays, braces, or mouth guards?

Yes                 Sometimes                  In the Past                  No

7.     Do you have food reactions, sensitivities, or intolerances?

Yes                 Sometimes                  In the Past                  No

8.     Do you have environmental allergies?

Yes                 Sometimes                  In the Past                  No

9.     Do you have any artificial materials in your body (implants, pins, joints, etc.)?

Yes                 Sometimes                  In the Past                  No

10. Do you lead a high-stress lifestyle, or have you experienced a stressful or traumatic event?

Yes                 Sometimes                  In the Past                  No