Environmental Influences Questionnaire
Name:___________________________________________________________

Date: _____/____/_____

There are over 70,000 chemicals commercially produced in the United States. The long-term effects of many of thesechemicals have never been investigated. But many chemicals are harmful in very low doses. Unless generated by thebody (formaldehyde, pentane), the body’s level for chemicals should be non-detectable, and not “low level”. Chemicals
are widespread in our environment, and constant exposure to low levels can cause dysfunction in many systems of thebody. The purpose in the following questions is to determine if any of your health problems can be a result of chemical
toxicity and to measure your TOTAL TOXIN LOAD.

Electromagnetic Factors

 Use typewriter correction fluid

 Live or have you lived within 200 yards from highvoltage wires or transformers
When? _________________________

 Use rug cleaners

 Live or have lived near an electric distribution
substation

 Use carbonless paper Bed is close to the main electrical current

 Use cleaning supplies

 Have a fan directly over your bed

 Use metal degreasers

 Have an alarm clock or radio close to your bed(plugged in) Do recreational painting

 Live or have you lived near a television transmitter

Formaldehyde Wear many dry-cleaned clothes Sleep with an electric blanket, heating pad Use disinfectants
 Use spot removers

 Sleep on a waterbed

 Noticed changes of your health since you moved
into your home

Position of your head of your bed is facing: Wear many polyester clothes and permanent press North You use Spray Starch South Have foam wall insulation

 East Have particleboard, chip board or interior plywood

 West Put up wallpaper in the last 2 years Work on a computer for longer that six hours/day

 Have foam cushions or foam mattresses

 Use a screening shield over your computer screen

 Live or lived in a trailer

 Live or have you lived near a power generating
station Worked in a laboratory

 Live near a radio tower

 Your home been insulated since your illness

 You use a cellular phone more than 2 hours per day Had new carpets.
When? _________________________________

 Use microwave ovens

 Use waxes and polishes on your floor Bed has a wooden backboard

 Been around resin glues and plastics

 Have fluorescent light fixtures

 Have exterior grade plywood on your home

What is your occupation?
____________________________________________________________________________________________________________________________________________________________________________________

 Home made of stucco, plaster or concrete

Toxin Exposure Have fire-proof material in your home

Trichloroethylene/TCE Work close to a copy machine Smoke in your home Worked in a printing shop
 Drink decaffeinated coffee

 Have a wood-burning stove Have draperies
 Have used acid-cured resin floor finishes

 Have a photography darkroom
 Use nail polish removerEnvironmental Influences Questionnaire Decongestants

 Use fingernail hardeners

 Hair sprays

Pesticides & Herbicides(Organochlorines, Organophosphate, Carbamate,Chlorinated Cyclodiene, Botanical & Microbial)
 Use pesticides

 Scented deodorants
 Scotch tape
 Newsprint Use weed killer

 Lysol You use cleaning fluids, waxes

 Epoxy

 Lived or worked at a dry cleaning plant Listerine Have been around wood preservatives

 Chloraseptic throat sprays

 Drink tap water Noxema Work with electrical equipment

 Mildew cleaners Have mothballs in your closets

 Perfumes

 Gasoline fumes bother you Air Fresheners

 Eat store bought meat Disinfectants

 Use insecticides

 Polishes Crop-surface sprays Glues Aerosols

 Waxes Fumigants Mouthwash
Volatile Organic Compounds(Paradichlorobenzenes, toluene, ethers, ketones,propane, polymers, tetrachloroethylene) Had home painted in the last 2 years Hard saucepan handles
 Smoke in the house Have you been exposed to chemicals?
When?________________________________

 Use cleaning solvents Have soft vinyl floors

 Have you had your home treated for termites
When?________________________________

 Handle propane and butane

 Wash own vehicle by hand.
What type of cleaners do you use? __________

 Get your clothes dry-cleaned
 Store dry-cleaned clothes in closets

Carbon Monoxide/Nitrogen Oxide/Sulfur Dioxide
 Have oil or gas stove Barbecue more than 2 times per month Work in a “tightly sealed building”

 Have water heaters

 Work close to a laser printer Chimney is damaged

 Use moth balls

 Live near a busy street

 Have nylon carpet

 Garage attached to your home

 Use air fresheners

 Smoke at home

 Have a workshop in the home

 Have an open fireplace

Phenols
Do you use the following?

 Burn candles Household cleaners

Ozone
 Use an electrical sewing machine Nasal Sprays

 Use power tools

 Styrofoam cups

 Use ion generators

 Cough Syrup

 Work close to a photocopier© Sequoia Education Systems, Inc2

www.FunctionalMedicineUniversity.com

Environmental Influences Questionnaire Worked in a rubber industry

Carbon Dioxide
 Work in a crowded work place Have poor ventilation at work

General MiscellaneousAsbestos
 Live in an old home

 Home is damp

 Have basement Molds
 Use a humidifier? If yes, when the last time you
cleaned it? _____________________________

 Have old ceiling tiles, plaster, insulation board andheating duct tape

 Use black hair dye (Nitrosamines)

 Lived in a large city with many trucks, buses etc.
 Lived near a building which was torn down Worked in beauty shop.
When? ________________________________

 Mother exposed to any unusual chemicals or drugs
during pregnancy (DES) Take any illicit drugs as an adolescent/young adult?
What type?______________________________

 Do you have your nails treated? Acrylic Adhesives

 Open your windows at home

Please note the “brand” of product you use
For example: Toothpaste: Crest
Shampoo: __________________

 Work in a machine shop
 Work in a garden?

Toothpaste:_____________

 Work or have you worked on a farm
When? ________________________________

Hair Conditioner:_________

 Have mercury fillings

Makeup:_________________

 Had mercury fillings removed?
When?_________________________________

Lipstick:_____________

 Been exposed to radiation
When?_________________________________

Make-up Foundation: ________
Deodorant:_____________

 Have a hot tub

Perfume:_______________

 Use chlorine or bromine

Hairspray:_____________

 Have a well

Shaving Cream:____________

 Work around PVC pipe (Vinyl chloride)

Cologne:_______________

 Home well ventilated

Facial Creams:_____________

 Moved to a new office in the last two years

Body Creams:______________

 Live in an apartment?
How old? ______________________________

Do you have hair permanents? Yes/No
If yes, how often?_____

 Eat at salad bars

Do you have hair colorings? Yes/NoIf yes, was it permanent or temporary?

 Eat raw fish (Sushi)
 Buy food from street vendors

Do you use Latex products?
 Baby bottle nipples

 For Women: Have breast implants. Yes/No
The implant was made of saline ___ silicone___ Balloons

 Has any type of metal been used in implants or joint
replacements in your body?
What type?____________________________
Where________________________________

 Bandages
 Diaphragms
 Hot water bottles
 Latex gloves

 Notice more symptoms at work than at home or viceversa?

 Dishwashing gloves

 Symptoms worse going into a mall

 Rubber dams for dental work Have you ever worked in a mall?
When?_______________________________

 Tires© Sequoia Education Systems, Inc

3

www.FunctionalMedicineUniversity.com

Environmental Influences Questionnaire Have live plants in your home

 Use an electric blanket

 Have pets in your home

 Have a ceiling fan Owned a new vehicle since your symptoms began Have material under your bed

 Furniture been put in storage or possibly fumigated Have real plants in your bedroom

 Stained furniture in the last 2 years

 Have artificial plants in your bedroom

 Have a tool shop in your garage

 Use aromatherapy in your bedroom

 Live on or near a golf course Burn scented candles in your bedroom

 Live in or near an industrial area

 Have central heat Lived or traveled outside the US.
Where?_________________________________

 Have a fireplace in your room
 Have an electric baseboard

 Bought new furniture?
What type of material? ____________________

 Use gas heat Installed drop ceilings

 Use an air filter in your bedroom
What type? _____________________________

 Painted indoors

 When was the last time you changed your filter inyour room? _____________________________

 Sided your home

 Have central air conditioning Changed your heating system, stove, clothes dryeror water heater Sleep with your windows open

 Lived in a brand new home

 Live close to a high traffic road

 Lived in a new office Smoke in bed

 Noticed changes of your health since you moved
into your home?

 Allow any pets in your room
What type?______________________________

 Have a water purification system?

 Have plugged in air fresheners

 Live near a landfill?
 Have a water filter on your shower?

Art and Leisure Activities

Describe the contents of your bedroom Make stained glass

 Silk-screening What type of mattress? ____________________

 Make pottery & ceramic products

 Have hardwood floors

 Make jewelry

 Have carpeting Buy art and craft supplies

 Have blinds Use airbrush and spray paints

 Have draperies

 Do quilting and weaving

 Use a foam pillow

 Gardening Use a feather pillow

 Make soapstone carvings

 Use a Dacron pillow

 Use acrylic paint Use wool blankets

What hobbies do you have? Please list:

 Use cotton blankets

1.________________________

 Use quilts

2.________________________

 Use synthetic blankets

3.________________________
Please indicate the occupation of your parents during your childhood:____________________________________________________________________________________________________________________________________________________________________________________© Sequoia Education Systems, Inc

4

www.FunctionalMedicineUniversity.com