Environmental Health Questionnaire

The purpose of this environmental health questionnaire is three-fold:

1. Current health and wellbeing: Your personal sensitivity to environmental contaminants is unique and reflects many known and unknown factors, including past exposures, genetics, epigenetics, and nutrient deficiencies. Use this questionnaire to explore how your personal sensitivity to environmental contaminants impacts your current health concerns.
2. Reduce your toxin burden: Use this questionnaire as a tool to identify unnecessary toxin exposures and eliminate them from your life.
3. Prevention: Environmental toxins work synergistically against our body’s natural repair mechanisms. Do not underestimate the cumulative impact of current and past exposures on your future health and quality of life.

For a broader discussion about Environmentally-Acquired Illness and the impact of environmental toxins on our health, please follow the embedded links and explore some of the additional resources listed below.

Personal Environmental Sensitivity

• Do you experience sudden symptoms (e.g. headache, shortness of breath), on exposure to fragrances, fabric softeners, moulds, exhaust fumes, or other environmental allergen?
• Do you have a sensitive sense of smell and notice odours that others can’t?(This includes things like mildew or off-gassing of new furniture or in a new car.)
• Have you had to reduce the recommended dose of a pharmaceutical, over-the-counter medication, or botanical preparation, because you’re too sensitive? Or have you had an unusual reaction to anesthetia?
• Are you prone to experiencing adverse reactions to medications? To alcohol (e.g. low tolerance, significant hang-over the next day)? Or caffeine?
• Is your skin sensitive to body care products, detergents, latex, or metal jewelry/buckles?
• Do you have more than 3 known food or environmental allergies?
• Are you much more likely than others in your home to catch a cold or flu?
• Have you ever submitted DNA for testing, such as for ancestry analysis (e.g. 23andme)? Ask your practitioner about using this data to explore your genetic makeup for detoxification and methylation. (Take a look at the “Dirty Genes” questionnaire by Dr. Ben Lynch on our website.)
• Do you have chronic health concerns that include generalized fatigue, wide-spread muscle pain, and fast heart rate?
• Did your health ever change suddenly following home renovations, moving to a new workplace, or moving into a new home?
• Do you experience discomfort or neurological symptoms (e.g. heat, tingling) in the ear, face, scalp, or body part when using a cell phone or electronic device?

If you find that your threshold for tolerance to environmental chemicals is declining, you’re not alone. Some people find that it starts suddenly after a significant illness or stress like Lyme disease or a car accident. Sometimes the chemical sensitivity progresses gradually to include EMF sensitivity or mould (mycotoxin) intolerance.  We have many tools to help your body get back on track with improved chemical tolerance! Reducing exposure is the first step. Please read on to more thoroughly explore where your exposures are coming from.

Lifestyle Exposures & Environmental Health

Personal Care Products

• How often do you use commercial cleaning products and detergents (e.g. Tide, bleach, Comet, dryer sheets, fabric softeners, floor cleaners)?
• How often are you exposed to chemical air fresheners or scents in your home, car, or workplace (e.g. FeBreeze, scented candles, mothballs)?
• Do you use deodorant that contains aluminum, parabens, or phthalates?
• Do you regularly use antibacterial hand soap (e.g. Triclosan) or hand sanitizers?
• What about scented soaps, shampoos, moisturizers, etc.?
• Do you use natural sun block (e.g. zinc oxide) or the chemical varieties instead?
• Do you sleep on a synthetic foam mattress or pillow?
• For menstruating women, do you use normal pads and tampons, or have you moved on to use a silicone cup?

Food & Water

• How often do you eat charred meats, smoked meats (e.g. sausage), or cold-cuts?
• What percentage of your food is organic (i.e. grown without the use chemical sprays intended to kill pests and weeds)?
• Is your water at home and work filtered (e.g carbon filter, or Reverse Osmosis)?
• If you drink well water, has it been tested for arsenic levels or herbicides like glyphosate?
• Do you store your food or water in plastic containers or with plastic wrap (e.g. saran wrap)?
• Do you cook with non-stick cookware that’s coated with Persistent Organic Pollutants (POPs)? (This can include brands such as Teflon. Non-stick ceramic coatings might be safest.) What about aluminum cookware?
• How often do you eat artificial sugars (e.g. NutraSweet, SugarTwin)?
• Was there ever a time when you consumed canned or fresh fish at least 3 times a week for 6 or more months?

Hobbies & Local Environment

• Are you regularly exposed to off-gassing from new materials (e.g. new construction materials, car, shower curtain, carpeting)?
• Do you live or work in a place where the windows are always closed? (This is especially important if the same place also uses a gas cookstove, gas or wood fireplace, or anything else that could negatively impact air quality.)
• Do any of your hobbies involve use of toxic materials or metals? Consider painting, print-making, stained-glass making, fishing, hunting, and pottery.
• Do you have pets that are regularly treated with topical chemicals for fleas, etc.?
• Have you ever smoked, chewed tobacco, or been exposed regularly to second-hand smoke?
• Does your home have a carbon monoxide detector?

Past & Current Environmental Exposures

Pesticides and Solvents:

• Have you ever lived or worked on a farm or orchard, where the farm or surrounding ones used insecticides, pesticides, or herbicides?
• How about regular exposure to a golf course?
• Have you ever been exposed regularly to paints, stains, glues, or epoxies? Consider nail and hair salons, and living spaces attached to a storage area (e.g. attached garage) for paint cans, gas containers, etc.
• Have you ever lived near a dry cleaner or been a regular customer of one?

Some fat-soluble chemicals are believed to be stored by the body in our fatty tissues so that diets that encourage fast weight-loss can pose health risks. If you’ve had significant exposure to these chemicals, please incorporate some protective measures or work with a qualified integrative health practitioner during your weight-loss regime.

Heavy metals & toxic materials:

• Have you ever lived or worked near heavy traffic, airport, or gas station? (This includes biking or walking regularly alongside busy streets.)
• What about near a dump site, landfill, refinery, scrap yard, or industrial plant?
• Have you had your home assessed for leaded pipes or old leaded paint (paint from before 1979)?
• Do you have any metal implants (e.g. IUD, dental implants and bridges, silver dental fillings (amalgams), joint replacements, screws or plates)?
• Did you ever “play” with mercury as a child, or have regular exposure to mercury via fluorescent light bulbs,
• Have you ever been exposed regularly to welding, solder, leaded batteries, metal-working or stained-glass working?

For a deeper look at heavy metal exposure please review our heavy metals questionnaire. Heavy metals can accumulate in the body and past exposure can impact current chronic health conditions, including neurological illness and heart disease. Testing for overall body burden of heavy metals is possible and requires the support of a qualified healthcare professional.

Radon, Radiation & Electromagnetic Frequencies:

• Do you frequently travel by airplane?
• Have you had your home tested for radon gas by KFL&A Public Health?
• Do you or have you ever lived close to cell phone towers, electrical stations, high-voltage power lines, or nuclear power stations?

You can learn more about EMF sensitivity here, and ways to reduce your exposure here.

Moulds & Mycotoxins:

Please review the Mould & Mycotoxin Illness assessment on our website to further explore how your chronic health symptoms might be correlated to mould sensitivity.

Early Childhood Exposure:

Now consider whether one of your main caregivers (usually your mother or father) was regularly exposed to environmental contaminants around the time you were born. This could include frequent air travel or employment in a mine, factory, auto-mechanic shop, print shop, or agricultural area. It can include occupations such as Hairdresser, Mortician, Photographer, and Dental Hygienist.

Resources:

Why Environmentally-Responsible Choices are also Healthy Choices

Planetary Health (see additional resources in the right-side menu)

International Society for Environmentally-Acquired Illness (ISEAI)