Exposure Questionnaire This questionnaire is meant to help determine various sources of exposure and risk factors for a variety of conditions. It will also be helpful in developing a specific detoxification program. Please check next to all of those that apply. Name First Last Email Home / Living RoomDo you have carpets that contain stain repellant and/or brominated flame-retardants?* Yes No What type of home do you live in?* House Townhouse Condo Do you use a cleaning service or live in a condo where you have no control over the products used to clean?* Yes No Do you have upholstery and furniture that are treated with stain repellants and/or brominated flame-retardants?* Yes No Do you have curtains that are treated with stain repellants and/or brominated flame-retardants?* Yes No Do you have PVC-containing mini blinds from Mexico or Asia?* Yes No Do you use chemical air fresheners?* Yes No Do you have any pets?* Yes No What type of animal do you have?* Do you have a litter box in your home?* Yes No Does your kitchen have vinyl floors?* Yes No Do you use plastic food wrap?* Yes No Do you use bottles or plastic containers labelled #3,7?* Yes No Do you microwave with plastic wrap?* Yes No Do you use nonstick cookware?* Yes No Do you use ceramic glazed cookware?* Yes No Do you use crystal tableware?* Yes No Do you use cleaners with chemical ingredients?* Yes No Do you use antibacterial soaps, dishwashing liquids or other cleaners that contain triclosan?* Yes No What products do you use to clean your home?* BedroomDo you have bed sheets that are wrinkle-resistant or made from pesticide-treated cotton?* Yes No Do you have moth-proof wool blankets or scatter mothballs?* Yes No Do you have a mattress with brominated flame retardants, or made from plastic or foam?* Yes No Do you wear dry clean only clothes?* Yes No Do you wear clothing with stain repellants, wrinkle resistance, brominated flame retardants, or pesticide-treated cotton?* Yes No Do you have electrical equipment around your bed (water bed, heating pad, electric alarm clock)?* Yes No BathroomDo you use products with synthetic fragrances?* Yes No Do you use antibacterial toothpaste or antibacterial mouthwash?* Yes No Do you use sanitary products bleached with chlorine or made of pesticide-treated cotton?* Yes No Do you have a porcelain enamel bathtub or fixtures?* Yes No Do you have vinyl shower curtains or fabric shower curtains with a water-repellent coating?* Yes No Home OfficeDo you have subflooring, wall covering, cabinets, furniture with a toxic finish? (any furniture painted before 1960)* Yes No Do you use computers with brominated flame retardants? (this does NOT include products from Apple, Bell, Fujitsu, Siemens, Hewlett Packard, Itachi, IBM, Intel, Matsushita, Panasonic, Motorola, NEC, Philips Semiconductors, Sony, Toshiba)* Yes No BasementDo you or have you used paint stripping, paints, varnishes, glue, adhesives, and solvents in your basement?* Yes No Do you use laundry detergents and fabric softeners which synthetic fragrances?* Yes No Do you use chlorine bleach?* Yes No GardenDo you use CCA pressured wood for your patio, fence or play equipment?* Yes No Do you use chemical pesticides for your garden?* Yes, currently Yes, in the past No Dental HealthDo you have any mercury fillings?* Yes No How many?* Have your fillings been removed?* Yes No When and by who?* Do you have any "white" fillings?* Yes No How many?* Do you have any root fillings?* Yes No Do you have any unhealed teeth extraction sites?* Yes No Have you ever had oral galvanism performed??* Yes No FoodDo you eat canned foods?* Yes No Do you eat chemical pesticide sprayed produce?* Yes No Do you eat chicken?* Yes No Do you eat fish / shellfish? (mercury)* Yes No Do you drink non-organic cow's milk? (hormones)* Yes No Do you drink non-organic cow's milk?Do you eat non-organic eggs (does not include free-range eggs)? (hormones)(hormones)* Yes No Do you eat prepackaged foods?* Yes No Do you consume aspartame?* Yes No Do you eat non-GMO (genetically modified organisms) foods?* Yes No Misc. QuestionsDo you fly frequently?* Yes No How often?* Do you live close to or have you ever lived close to electrical towers?* Yes No Did you grow up with exposure to pesticides in an agricultural centre?* Yes No When and what?* Have you spent any time working in a dark room?* Yes No Do you have any known mold in your home?* Yes No Have you ever lived in a home that has been treated for bed bugs?* Yes No Have you ever worked with asbestos?* Yes No Where were you born?* Do you have any other exposures that were not mentioned in this questionnaire??* Yes No Do you have any surgical implants or devices?* Yes No Do you have any surgical implants or devices?* Yes No Do you have a history of chemotherapy?* Yes No Do you have a history of radiation treatment?* Yes No How many x-rays have you had in the past 10 years? (approx.) Childhood ExposuresThese questions relate to a child undergoing careDo your plastic feeding bottles or glasses used by your child have the #7 on the bottom of the container? Yes No Do you use latex rubber nipples on bottles? Yes No Do you use PVC containing toys or soothers? Yes No Do you/did you use disposable diapers? Yes No Do your children’s clothing have plastic labels and/or are they treated chemically? Yes No How old is your crib? Do you know the source of the paint? Yes No What products do you use on your children to wash their hair / bodies? Has your child grown up on a farm? Yes No Which pesticides / herbicides were used on the farm? Do you live under or close to hydro towers? Yes No Do your kids play in sandboxes? Yes No Does your child have any other know exposures that were not mentioned in this questionnaire? CAPTCHANameThis field is for validation purposes and should be left unchanged.